Record Keeping

IMPORTANCE OF GOOD RECORD KEEPING

Record keeping is an integral part of nursing, midwifery and health visiting practice. It is a tool of professional practice and one that should help the care process. It is not separate from this process and it is not an optional extra to be fitted in if circumstances allow.

(NMC 2010)

Good record keeping will help to protect the welfare of both the patient and practitioner by promoting:

high standards of clinical care
continuity of care
better communication and dissemination of information between members of the interprofessional health-care team
the ability to detect problems, such as changes in the patient’s condition at an early stage
an accurate account of treatment and care planning and delivery.

The quality of record keeping is also a reflection of the standard of nursing practice: good record keeping is an indication that the practitioner is professional and skilled whereas poor record keeping often highlights wider problems with the individual’s practice (NMC 2010).

COMMON DEFICIENCIES IN RECORD KEEPING

Nearly every report published by the Health Service Commissioner (Health Service Ombudsman) following a complaint identifies examples of poor record keeping that have either hampered the care that the patient has received or have made it difficult for health-care professionals to defend their practice (Dimond 2005).

Common deficiencies in record keeping encountered include (Dimond 2005):

absence of clarity
failure to record action taken when a problem has been identified
missing information
spelling mistakes
inaccurate records.

PRINCIPLES OF GOOD RECORD KEEPING

There are a number of factors that underpin good record keeping. The patient’s records should:

be factual, consistent and accurate
be updated as soon as possible after any recordable event
provide current information on the care and condition of the patient
be documented clearly and in such a way that the text cannot be erased
be consecutive and accurately dated, timed and signed (including a printed signature)
have any alterations and additions dated, timed and signed; all original entries should be clearly legible
not include abbreviations, jargon, meaningless phrases, irrelevant speculation and offensive subjective statements
still be legible if photocopied
identify any problems identified and most importantly the action taken to rectify them.

It is important to record all aspects of patient monitoring. Some observations will be recorded on the patient’s observation charts (e.g. the intensive care unit’s [ICU’s] observation chart and early warning chart – Fig. 19.2). Dates and times should be clearly visible and standard coloured ink should be used following local protocols. It is also important to ensure that an accurate record is made in the patient’s notes. In particular it is important to include interventions and any response to the interventions.

Fig. 19.2 Standard observation chart (Walsall Hospitals NHS Trust).