Why record keeping matters
The Vital Role of Comprehensive Record Keeping in Nursing Practice and Legal Proceedings
In the realm of healthcare, the significance of comprehensive and accurate record keeping cannot be overstated. Nurses, in particular, hold a substantial responsibility when it comes to documenting their interactions, assessments, and interventions with patients. The Nursing and Midwifery Council (NMC) recognises that nursing records are not just a formality but a fundamental aspect of nursing practice, serving multiple crucial purposes.
Who are you accountable to?
- Criminal Justice system (criminal law)
- Civil Legal System (litigation)
- Employer (contract of employment)
- Patients and the Public (treatment)
- Peers (team work, criteria set by colleagues)
- Regulatory body (NMC)
- Yourself (individual responsibility)
The NMC code of conduct is the foundation of good nursing and midwifery practice, and a
key tool in safeguarding the health and wellbeing of the public. The people in your care must be able to trust you with their health and wellbeing.
“Keep clear and accurate records relevant to your practice
This applies to the records that are relevant to your scope of practice. It includes but is not limited to patient records.
To achieve this, you must:
10.1 complete records at the time or as soon as possible after an event, recording if the notes are written sometime after the event
10.2 identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need
10.3 complete records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements 10.4 attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation
10.5 take all steps to make sure that records are kept securely
10.6 collect, treat and store all data and research findings appropriately.”
A Communication Vehicle for Healthcare Providers
Nursing records are a vital means of communication among healthcare providers. They enable the seamless transfer of critical information regarding a patient’s condition, treatment plan, and progress. In a complex and fast-paced healthcare environment, where multiple professionals are involved in a patient’s care, detailed records ensure that everyone is on the same page. This coordination is essential to providing safe and effective care.
Determining the Appropriate Level of Care
Nursing records play a pivotal role in determining the appropriate level of care for patients. They serve as a historical account of a patient’s medical journey, allowing healthcare professionals to make informed decisions about the course of treatment. These records help healthcare providers track trends, identify potential issues, and make necessary adjustments to a patient’s care plan.
Credible Evidence in Legal Proceedings
Perhaps one of the most critical aspects of maintaining comprehensive nursing records is their role as credible evidence in legal proceedings. In cases of clinical disputes, medical malpractice, or disciplinary actions, these records can be the most crucial pieces of evidence. They can establish whether the care provided to a patient met the required standard and demonstrate that healthcare professionals fulfilled their duty of care.
The NMC has been clear in its expectations regarding record keeping. According to the “Record Keeping – Guidance for nurses and midwives”, nurses and midwives are bound by specific rules:
- Keep clear and accurate records of discussions, assessments, treatments, and medicines given.
- Complete records as soon as possible after an event has occurred.
- Do not tamper with original records.
- Ensure that entries made in paper or electronic records are clearly attributable to the responsible healthcare professional.
- Keep all records securely.
As the saying goes, “If it isn’t recorded, it didn’t happen.” This simple adage underscores the critical nature of comprehensive record keeping.
The Complexity of Cases Demands Comprehensive Records
The complexity of healthcare cases underscores the need for thorough record keeping. In situations where patients present with complex problems, deviate from the norm, or are confused or disorientated, detailed records become even more important. Such records not only provide clarity but also help ensure that the care provided was appropriate and safe.
Types of Records and the Scope of Responsibility
The principles of good record keeping apply to various types of records, including handwritten clinical notes, emails, letters to and from other health professionals, laboratory reports, X-rays, printouts from monitoring equipment, incident reports, videos, tape recordings of telephone conversations, and even text messages.
In response to concerns about the time constraints and staff shortages in healthcare, it’s important to remember that maintaining good records is not just an administrative burden. It’s a professional responsibility that ensures effective communication and safe patient care. When handled correctly, comprehensive record keeping can also help healthcare professionals avoid being involved in NMC or court proceedings, protecting their professional reputation.
Avoiding Claims and Upholding Professional Standards
The NMC guidelines for records and record keeping highlight that the quality of record keeping is a reflection of a healthcare professional’s standard of practice. Careless or incomplete record keeping, they say, can raise concerns about an individual’s competence and professionalism. It is, therefore, essential to maintain records diligently and with attention to detail.
Ensuring that records are factual, complete, and up to professional standards is not just a matter of fulfilling a regulatory requirement; it’s a commitment to providing the highest quality of patient care and maintaining the integrity of the profession.
In conclusion, nursing records are more than just paperwork; they are the backbone of effective patient care and a lifeline in legal proceedings. The NMC’s emphasis on good record keeping is a reminder of the profession’s commitment to patient safety and maintaining high standards of practice. In an environment where lives and professional reputations are at stake, meticulous record keeping is not an option but an ethical and legal imperative.
