Record keeping: developing good practice

THE LAST decade has seen a shift of attitude within the nursing profession towards the importance of record keeping. This change has been brought about predominantly by the promotion of patients’ rights and the empowerment of patients and relatives to be involved in their care, through the Patient’s Charter (DoH 1991). This has now been superseded by Patient Focus and Public Involvement (Scottish Executive 2001). This partnership approach has resulted in an increase in patients and relatives challenging the medical and nursing professions about their care and treatment. Healthcare trusts have developed comprehensive and robust complaints procedures which reflect this change in culture and this, in conjunction with an increase in litigation (Donaldson 2000, Moody 2001), has resulted in the nursing profession becoming more pro-active in developing and monitoring practice in record keeping. Flawed communication is repeatedly identified as a contributory factor in investigations into complaints or legal proceedings (Wilson 2001). Thorough documentation might, therefore, reduce the incidence of complaints. However, accurate record keeping is not merely concerned with nurses protecting themselves from litigation; it is primarily aimed at enhancing patient care. Precise record keeping can protect the welfare of patients by promoting continuity and consistency of care (UKCC 1998). It can also lead to enhanced evaluation of clinical practice. This article explores the educational needs of a group of nurses with regard to their ability to comply with the UKCC’s guidelines concerning record keeping (UKCC 1998). This was achieved by reviewing the relevant literature, examining the UKCC’s (1998) guidelines and carrying out a needs analysis among nurses working in Ayrshire and Arran Primary Care NHS Trust. A literature review was carried out to identify the main positive and negative issues, in relation to current national practice in record keeping: the salient topics for this exercise were quality and legal implications. Professional responsibility and accountability are among the most important reasons for high-quality documentation and were to be core to any training programme developed. Quality Young (1995) defines record keeping as: ‘any permanent form of information recorded about a patient or client’. The contents of nursing records must demonstrate a skilled and safe practitioner working within UKCC guidelines. Hence the quality of entries into patient records should reflect this. Fulbrook (1998) identifies two main themes that underpin the need for quality record keeping: the clinical needs of patients and legal implications. Iyer and Camp (1995) describe documentation as the most significant professional function of the registered nurse, since effective recording of patient care will demonstrate the patient’s responses to nursing interventions. They state: ‘nurses make complex, sophisticated decisions concerning patient care, yet nursing documentation does not always reflect those decision-making responsibilities. Documentation must clearly communicate a nurse’s judgement and evaluation’. A high standard of nursing documentation is vital since it may be used to inform other professionals subsequently involved in the care of the patient (Fulbrook 1998). Common flaws in documentation identified within the literature include: lack of brevity, assumptions being made, use of abbreviations, and the use of unnecessary emotive language. Aumiller and Moskowitz (2000) offer a few simple rules when recording patient care, which include recording facts rather than opinions and avoiding confusing generalisations such as ‘patient doing well’. Legal perspective It is important for nurses to acknowledge that any record documenting patient care may be used as evidence by a court or as part of an investigation or complaints procedure. It is often not until an allegation of professional negligence or a complaint is made that a nurse appreciates the importance of keeping comprehensive Literature review Chris Rodden RGN, BSc, is Clinical Trainer; and Maureen Bell RGN, RM, RHV, BA, Dip Child Protection Studies, is Designated Nurse for Child Protection, Ayrshire and Arran Primary Care NHS Trust, Ayr. Email: chris.rodden@ aapct.scot.nhs.uk Record keeping: developing good practice