Record keeping: Guidance for nurses and midwifes (2009)
In 2009 the Nursing and Midwifery Council (known as the NMC) issued revised guidelines entitled: Record Keeping: Guidance for Nurses and Midwifes (2009). According to this guideline, suitable quality records means information needs to be legible; timely; relevant; consistent; accessible, objective; factual and complete. This guideline states that “Good record keeping is an integral part of nursing and midwifery practise, and is essential to the provision of safe and effective care.” (NMC 2009). This essay will consider four of the principles from the NMC Record Keeping: Guidance and Midwifes (2009). Further, based on these four principles, this essay will focus on the impact on record keeping in a patients care plan and will then go on to consider how good record keeping is maintained in relation to a patients care plan. References will be provided in support of the points made in this essay and will also be relative to what the writer has observed in practise placements. Finally, conclusions will be drawn which summarises the points relating to this essay and will consider the evidence to draw on its conclusion.
The first point selected is point one which states that “Handwriting should be legible” (NMC 2009). Sokol D and Hettige S (2006) citing Gakhar H, Sawant N, Pozo J. Audit of the legibility of operation notes. In: Royal College of Surgeons of Edinburgh Audit Symposium 2005. Edinburgh: RCS Ed, 2005 state that three surgeons audited the legibility of 40 randomly selected operative notes from an orthopaedic ward in a large British hospital. Two nurses, two physiotherapists and two medical house officers were asked to rate the legibility of the notes as ‘excellent', ‘good', ‘fair', or ‘poor'. Only 24% were rated ‘excellent' or ‘good' and 37% were deemed ‘poor'. This research suggests a very high percentage is the result of illegible handwriting, which in turn could suggest that care could be impacted on in over a third of the patients. McGeehan R (2007) citing Griffith (2004) suggests that the standard of handwriting is also part of a nurses duty of care towards patients. If harm befalls a patient because colleagues were not able to read a nurses handwriting, then they may be accused of liability in negligence. It should be remembered that legibility includes the signature of the person making the entry. McGeehan R (2007) citing Griffith (2004). The writer of this essay, while on placement, discovered illegible handwriting in the early years of a chronology which formed part of a patient's record. This led the writer to seek clarification of what was stated, some words could not be read and the original signatory had left many years ago, this was but one negative impact of illegible handwriting and fortunately in this case the entries where dated a few years back but could have lead to problems at the time. Illegible handwriting on a care plan can appear to be inaccurate and these inaccuracies can lead to delays in carrying out the provision of care according to the care plan along with contributing to errors. Other impacts are that medication could be issued incorrectly, people can make incorrect assumption, incorrect care could be implemented and patients could become confused and agitated by not being able to read their care plan. Mistakes made due to illegible handwriting can have financial and legal issues also. If a case goes to court then the first things looked at are the records, if handwriting is illegible then the writer and their professionalism can be discredited from the onset. Culley F( 2001) suggests that “Once a habit, it becomes second nature to write good, copious records.” Nursing & Residential Care, August 2001, Vol 3, No 8 citing Chapman N (1997) A coroner's view on the keeping of medical records. Health Care Risk Report April: 1 This suggests a positive impacts of good record keeping in a patients care plan, if consistent it becomes second nature and becomes a model to others. A good example of this was witnessed by the writer of this essay on placement when their mentor was demonstrating how they filled in some sections, they could demonstrate that they always filled in the details the same way consistently, it had become that ‘second nature' to do it right. The aim of good record keeping is to ensure that colleagues have the information from the records to know what care and treatment has taken place, what is currently taking place and the future care” Dimond B (2005). A care plan should be legible for colleagues and the patient to be allowed to extract this information easily and this cannot be done if not legible. Good legible handwriting should show a nurses professionalism, people should be able to clearly read what is written, by whom and when and the care plan should appear accurate as a result in turn improving the care of the patient. In order for legible handwriting to be maintained in a care plan, a consistency should be shown. Good examples of care plans should allow for legibility, an index of signatures at the beginning of each care plan including name, position and your signature. If unsure about what any handwriting says a nurse should always seek clarity. Highlight any poor handwriting or potential error due to illegible writing. The patient should feel comfortable discussing illegible handwriting and nurses should encourage feedback without repercussions. Highlight any signatures that are not on the index. Double check anything you are unsure about in a patients care plan. “Regular audit is essential to identify errors in record keeping and to maintain reasonable standards” Dimond B (2005) This suggests that an audits should be carried out and that they can identify at an earlier stage any trend of poor record keeping and action accordingly.
The second point selected is point five which states that “records should be factual and not include unnecessary abbreviations, jargon, meaningless phrases or irrelevant speculation”. (NMC 2009). Care plans are used not only to communicate with and work with the patients but to also allow staff to communicate efficiently and record the care that has been carried out. It is therefore important to use simple clear, factual and relevant information while recording information in a way that everyone understands. “Providing safe and high-quality patient care is dependent upon effective communication between health care professionals, patients, and patients' families”. Schyve P M J Gen Intern Med. 2007 November; 22(Suppl 2): 360–361. Published online 2007 October 24. doi: 10.1007/s11606-007-0365-3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2078554/ accessed 14th Jan 2010. Information included in the care plan should be based on the facts involved, examples being, what was actually seen, what actually happened. The difference in fact from a nurse's opinion should be clear and distinguished when information is recorded in a care plan. Many patients will not understand nurse jargon, abbreviation or technical information written in their care plan. Griffith R (2007) states that the temptation to use jargon and abbreviations as a form of professional shorthand is compelling for busy health professionals. The risk of miscommunication increases dramatically by using this shorthand. Griffith R Nurse Prescribing 2007 Vol 5 No 8 http://www.internurse.com.ezproxy.stir.ac.uk/cgi-bin/go.pl/library/article.cgi?uid=27147;article=NP_5_8_363_366 Accessed 19/01/10. The impact of this is that it is not patient centred care and contravenes the NMC code which states that ‘ You must share with people, in a way they understand, the information they want or need to know about their health' NMC (2007). One nurse's abbreviations may differ from another and abbreviations should be avoided where possible but if necessary an index of abbreviations should be supplied to the patient and form part of their care plan. A poor example of this was witnessed by the write of this essay recently on placement when NHS 24 sent a contact sheet to the placement to attend a patient; the contact sheet was full of abbreviations with no index included as a student nurse the writer was unaware of what some of these meant and had to ask for assistance. A patient requesting to see their notes would also suffer the same problem.
Wood C (2003) states that to write full descriptions would impact on the time taken to enter records. However, he also highlights the dangers where abbreviations could mean different things to patients and staff. This examines the argument that nurses don't have time to complete accurate records but prompts that an agreed list, which should be audited on a regular basis be attached to the care plan. A factual care plan that is written in a relevant and easily understood manner that promotes clear communication should be maintained. This then should allow others especially the patient, to pick up at any point and be able to follow their care plan.
The third point selected is point thirteen which states that “the language that you use should be easily understood by the people in your care”. NMC (2009). Each patient is unique when it comes to language that they can understand; they each have their own level of communication and understanding. Cully F (2001) Suggests that in providing sufficient information to allow patients to make informed decisions is an essential component of the duty of care, and it supports the ethical principles of individuality. This information needs to be provided in a patients care plan in such a manner that there leaves no doubt to the patient. Dougherty L and Lister S (2008) Page 23 comment that care plans should be written wherever possible with the involvement of the patient, in terms that they can understand including relevant core care plans that are individualised, signed, dated and timed. This suggests that writing the care plan with the patient allows them to gain the information that they may require about their condition and the treatment options in a manner that allows the patient to understand the language used, on a level that meets their communication needs. An excellent example of this was witnessed by the writer of this essay on placement. It involved their mentor sitting with a new resident and creating their care plan from the beginning, several times the resident requested what something meant and the mentor explained clearly and rewrote section of the care plan to accommodate the residents understanding. Ambiguity may also be an issue that impacts on a patients care plan, “statements may be interpreted differently” Dimond B (2002). She suggests that examples like ‘had a good day' may mean several things to a patient for instance, they may have slept all day or may have been awake all day. These types of generic statements do not provide the patient with the information they need. The writer of this essay witnessed statements like ‘settled morning' and ‘slept well' on a recent placement; again these are general terms which should be avoided. A Care plan written with the patient should also have clear and concise instruction, this should be as specific as possible allowing the patient to also be involved in a clear manner, colleagues and other professions may be aware of what a statement may mean but the patient may not. ‘You should also write your instructions according to who they are intended for. For example, writing in the care plan to observe for signs of inflammation regarding a wound is not specific enough, as not everyone will know what these signs are. Ideally, you should write: ‘...such as increased pain, swelling, redness and heat.' Wright K (2005). In maintaining clear language the patient's wellbeing is vital and if the patient is informed and understands what is written in their care plan then that contributes to their wellbeing. Language in a care plan should be clear and unambiguous and audits should be carried out regularly. “Audits are a good method of improving and sustaining a high standard of record keeping. The Audit Commission (2002), in a review of health records, found that subjecting records to audit cuts down dramatically on errors and poor standards.” Griffith R (2004) British Journal of Community Nursing, 2004, Vol 9, No 3.
The fourth and final point selected is point two which states that “all entries to records should be signed. In the case of written records, the person's name and job title should be printed alongside the first entry”. NMC (2009). Signatures are very important as a nurse has a duty to carry out the care plan and subsequently apply their signature, this helps to give evidence of their involvement and to demonstrate that their duty of care has been carried out. Griffith R (2004) suggests that care plans require to be detailed thoroughly and be sufficient enough to exhibit that anyone responsible for recording entries in the care plan has discharged their duty of care. This highlights that as a nurse discharges their duty they are signing and accountable for the actions and information entered into the care plan. This not only impacts on other professions awareness of acknowledged detail in the care plan but also allows the patient to see that their care plan is being carried out. Dimond B (2005) suggests that it is essential that an author of an entry in a health record is clearly and easily identifiable. An example of this being important would be to contact the signatory to discuss the patient or the care in their care plan. Griffith R (2004) British Journal of Community Nursing, 2004, Vol 9, No 3. This leads to the importance of also ensuring that the nurse's name and title is printed on their first entry of each page, which allows the patient and other professions to not have to constantly flick through the care plan to identify the signatory. There are many instances of poor practise when coming to signing an entry, in a case highlighted in the NMC Fitness to Practise Annual Report 2004 -2005 regarding a nurse working on the morning shift who had received a hand-over from the respondent nurse after night duty. Subsequently, when she went to administer the morning medication, she saw that none of the drugs at 10pm had been signed for in the medication administration record. This example of poor record keeping could potentially have lead to further delay in the implementation of the care plan and possible the patient suffering harm, this is poor practise and does not support the delivery of the service to the patient. In maintaining this procedure all signatures should be legible and contemporaneous to the record entry. Good examples of this were witnessed by the writer of this essay on placement as their mentor would write not only their signature at the point of action but also date and time it. A clear print of the name and position should be on the first entry of each page of that particular person writing the entry. A good example of this was witnessed by the writer of this essay several times when their mentor carried out this procedure routinely and without fail, this led to the care plan signatures being identified easily. A Nurse is accountable for their care and the correct signature is a factor in taking responsibility and understanding the relevance of this action. It should be noted that All NHS employees are responsible for any health records which they create or use. This responsibility is established and defined by the law (Public Records (Scotland) Act 1937).
Therefore in conclusion the consequences of poor record keeping should promote the maintaining of a good standard of relevant record keeping in line with the NMC (2009) record keeping guidance. In the NMC Fitness to Practise Annual Report 1st April 2008 to 31st March 2009, the investigating committee received one thousand seven hundred and fifty nine new cases of complaint referrals. Classified as allegations of failure to maintain adequate records was 8.52% which was one hundred and fifty records. It would seem reasonable to suggest that this sounds quite a low figure but the impact of the potential consequence of even one record are substantial. There are legal aspects, “Mistakes and missing information in records are common and are a major contributory factor in medical errors and poor clinical care, leading to complaints and medical negligence cases.” E Health Insider Sept 2007citing RCP. http://www.e-health-insider.com/news/3022/rcp_launches_generic_record-keeping_standards Accessed 18/1/10 A nurse should bear in mind that any entry made in a care plan can be scrutinized under a court of law.They have an accountability to maintain their records as a record is considered to be a legal document because it contains information about the care that has been planned and delivered to a client or patient and because it may be requested by a court of law (Dimond, 2002). Dimond B (2002). Legal Aspects of Nursing. Third Edition. London. However, good record keeping is not merely regarding a nurse protecting themselves from legal proceedings but good record keeping in regards to a patients care plan is firstly aimed at improving a patient's care. McGeehan R (2007) states that ‘records should provide a complete patient journey' McGeehan R (2007) Best Practise in record- keeping. Nursing Standard. 21, 17, 51-55. The suggests that the care plan of the patient is there for the patient to follow and understand at a level that they feel involved in, and also for colleagues and other professions to pick up a care plan and know exactly the plan involves and continue their care in line with it. The risks to a patient can be considerable the Audit Commision 2009 stated that Auditors identified issues relating to the quality of records at 80 per cent of trusts (England) and, in one case, the number of records classified as unsafe to audit represented over 16 per cent of the sample reviewed. This commission further states that this presents not only financial risks but more importantly raises concerns from a clinical and patient safety perspective. Improving the quality of records will help to improve the quality of care.
Audit Commision 2009
Ethical aspects should be promoted in that a nurse has a duty of care to the patient and themselves, promoting professionalism and care. The Audit Commission (2002), in its review of health records, found that subjecting records to audit cuts down dramatically on errors and poor standards. Nurses should be able to evaluate and audit their records formally and informally, to review how the record reflects the care they give even before the content is read. McGeehan R (2007). Regular audits should be carried out not only for self assessment purposes but to also highlight poor practise and should involve all relevant care team members. ‘Part of a nurse's professional responsibility is to inform a senior staff member of any incidences of poor record keeping. McGeehan R (2007) Best Practise in record- keeping. Nursing Standard. 21, 17, 51-55. On a recent placement the writer of this essay witnessed an audit being carried out and this was routinely done each month, the lessons were learned from these audits and poor record keeping ha become minimal as a result. Proper record keeping in a patients care plan is an important aspect of nursing A good care plan is required for good practice. Healthcare is now a multidisciplinary process and in order to maintain efficient treatment for patients it is important that a nurse, the patient and other professions have access to good quality patient records which are reviewed regularly to ensure that the service is kept to a professional standard and maintain patient care and safety.