Patient Safety The Importance of good record keeping

The purpose of this essay is to look at four of the principles from the Nursing Midwifery Council (NMC) document, principles of good record keeping. The NMC is the United Kingdom’s regulator for the nursing and midwifery professionals. It is a professional’s responsibility to follow the NMC code, principles of good record keeping, to help safeguard the health and wellbeing of the public (NMC, 2009). These four principles chosen states, “Individuals should record details of any assessments and reviews undertaken and provide clear evidence of the arrangements that have been made for future and ongoing care, including any details of information given about care or treatment” (NMC, 2009). “Ensure records should be accurate and recorded in such a way that the meaning is clear” (NMC, 2009). “Where appropriate the person in your care or their carer should be involved in the record keeping process” (NMC, 2009) and finally “Individuals have a duty to communicate fully and effectively with colleagues, ensuring that they have all the information they need about the people in their care” (NMC, 2009). In addition to these four principles, this essay is going to discuss each principle and the impact that the principles have on a patient’s care plan and how the principles maintain within a patient’s care plan.

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Record keeping is a fundamental part of nursing practice (Giffiths et al, 2007:1324-1327). The role of good record keeping is to ensure that all healthcare professionals know what care and treatment the patient is receiving. The first principle of good record keeping being discussed states “individuals should record details of any assessments and reviews undertaken and provide clear evidence of arrangements that have been made for the future of ongoing care. This should also include details of information given about care and treatment” (NMC, 2009).

One of the main evidenced based records in a care setting is a care plan. A care plan is a written record that informs individuals about the care and treatment of the patient (Barrett et al, 2009:5-6). Care plans develop using the nursing process. This involves a systematic approach involving assessment, planning, implementing and evaluating. This method provides a framework for professionals, which enables the making of a care plan to be developed, allowing professionals to meet the needs of the patient and protect their welfare (Wright, 2005:71-73). When admitting a patient into a care environment undergoing an assessment is essential. This should cover all basic needs such as hygiene, social, physical and safety needs of the patient, which would also include internal homeostasis needs, for instance temperature, pulse, respiration and blood pressure (Geyer, 2007:29-30). While patients care is ongoing, a document that is widely used within an acute side of the health care setting is EWS; this early warning sign document is a tool that protects the welfare of patients while receiving care from professionals. This tool can enable early detection of patient’s deterioration, based on measuring vital signs. This tool can highlight risk when monitoring patients and detect when the need for further intervention is required of skilled practitioners (Mohammed et al, 2009:18-24). Assessments can involve a variety of tools the purpose of these tools is to help professionals do their job properly and help toward assessing priority of care (Barrett et al, 2009:87-94). Assessing and planning are ongoing while the patient is receiving treatment. Documenting in a patients record while care is ongoing shows clear evidence of what as to be established, demonstrating the interaction that multi disciplinary teams provides, from the time a patient is admitted in to a care setting to when they are discharged (Barrett et al, 2009:20-23).

Within a care plan relevant information is stored about the patient, this should enable all professionals to develop a knowledge of the patient and enable them to have an empathetic understanding of the social, psychological and physical wellbeing of that individual (Barrett et al, 2009:47-56). A patients individual file will also contain details about the history of the patient, this can highlight any risk apparent, ensuring all professionals delivering care to individuals are aware of the patient’s condition, any known allergies, care required to be delivered and any treatment the patient is receiving.

The assessment and planning stage of the nursing process provides an accurate method of which the care plan document can guide professionals. The implementing stage enables professionals to deliver the care agreed and planned throughout written communication. The evaluating stage enables professionals to plan effectively. These four methods of the nursing process is a requirement when developing a care plan this then enables multi-disciplinary teams to be able to provide effective care when protecting the welfare of patients (Wright, 2005:71-73). Documenting the whole care planning process from assessment to evaluation as soon as it has happened is very important. Incomplete documents can cause the patients to suffer through no fault of their own; professionals have a legal responsibility to record documents. Documents need recording in multiple ways. However, written and electronic methods are the main ones widely used within a care environment, with whatever method used records should remain accurate and easily understood. The principle of good record keeping from the NMC, 2009 also suggests, “Records should be accurate and recorded in such a way that the meaning is clear” (NMC, 2009). Implementing good record keeping in a care plan is relevant for the importance of promoting the welfare of patients.

Clinical records shared the whole time a patient is receiving care or treatment and all health records should remain legible. Health professionals read records on a daily basis and it is important that the information in documents can be understood (Powell, 2009:300-301). Records can contain poor handwriting, which can then become very difficult to read, this can have an effect on care delivered to the patient. If individuals do not understand the writing within a patient’s records, mistakes can occur and put patients at greater risk. Health care records provide a lot of information about patients and it is vital it remains correct. The type of errors made when recording information can include, unreadable handwriting, jargon, spelling errors, typing errors and not recording essential information. Missing out information while documenting in records can put a patient at jeopardy and this highlights a cause for concern. For instance, a patient takes their medication but the nurse who gave the medication forgot to document it. If professionals do not receive information of when, what time and the date medicines administered to a patient, it may mislead other nurses taking over from another shift causing professional errors and risk of an overdose may occur to the patient (Dimond, 2005:568-570).

When recording in medical documents using medical abbreviations can be confusing, especially if the nurse is not familiar with the medical terminology. Professionals perform shortening down medical terminology into a variety of abbreviations throughout healthcare. The nursing and midwifery council makes it clear that abbreviations do not shorten, as there are dangers in using them. Professionals maybe mistaken by abbreviations in documents, this is when misunderstandings can occur. If abbreviations are mistaken and assumed to stand for something else, if implemented it can cause harm to the patient. For instance NFR; not for resuscitation or either way this could mean neurophysiological facilitation of respiration, which is a physical therapy. This abbreviation could cause fatal consequence if it suggests in a patient document that the patient is not required to have NFR and it does not make it clear within that record. Eliminating abbreviations when recording information is crucial as all records should express a clear detailed response (Dimond, 2008:196-198). Information in records should remain clear and accurate, as they are a legal document, for not only the safety of the patient but it also protects individuals from charges of negligence and other forms of malpractice. If a patient comes into any legal disputes, documents should remain professional as it is an individual responsibility as a professional to be legally responsible for what they write and all records should be legible to stand up in court if necessary (Powell, 2009:300-301), this shows how crucial record keeping is. Brooker & Waugh 2007 states, “If nursing care is not written down then it did not happen”.

When documents are being produced, “where appropriate the person in your care, or their carer, should be involved in the record keeping process” (NMC, 2009). This principle is an ongoing development throughout nursing practice, as well as involving patients in any decisions about care and treatment. Communication between nurse and patient develop to deliberate on the arrangement of care. Information within this discussion may come from close family members or carers, if the patients are not able to speak for themselves. Professionals require information from relatives and other individuals close to the family, this is vital within the process of record keeping. Exchanging information is essential to provide safe care towards the patient.

During development of record keeping it is important to involve the patient or carers to confirm the care discussed, this is important because the client’s care needs clarifying with the overall concept of the care plan and the process of its delivery. This enables the sharing of information throughout multi-disciplinary teams and allowing professionals throughout a variety of services to have access to medical records whenever they may require it (NMC, 2008). Patient’s records can be vital to staff who do not know the patient well, individuals giving consent for their file to be shared helps professionals to do their job. This then allows the individuals to provide a duty of care and enables professionals to protect the welfare of their patients.

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The last principle additionally advises, “Individuals have a duty to communicate fully and effectively with colleagues, ensuring that they have all information they need about the people in their care” (NMC, 2009). Nursing records are an evidence based communication tool; healthcare records are largely significant in communicating detailed information from one service to another. Clinical records are a source of communication throughout the healthcare sector, providing information to protect the wellbeing of individuals. It is essential that good communication is able to develop throughout multidisciplinary teams, ensuring all information exchanged concern patients for which professionals deliver care. When professionals are exchanging information, it provides a foundation for which the continuity of care to patients can continue. Information reported should be clear to professionals so they are up to date of the client’s condition, not only verbally but also manually. (McGeehan, 2007:51-54). Verbal communication throughout handovers remains essential to practice; handing over information at the end of a shift can be quite brief and having written documentation gives professionals the opportunity to look up on patient’s information, which will hold important details regarding the patient. This is most valuable especially for staff covering shifts; on some occasion’s professionals contact relief staff members to cover staff shortage. If individuals giving care do not know the patient, it enables them to read up and gain an insight of the patient, including medical history, current treatment and what care to be delivered, therefore enabling them to deliver care confidently (Featherstone, 2008:860-864).

However, discussing these four principles regarding the process of record keeping, it highlights the vast amount of impact these principles can have throughout a care plan document. This involves communicating throughout recorded documentation alerting multi-disciplinary teams of patient’s details based on facts. This allows professionals to know what the patient requires and continue the care agreed to protect the patient from any harm. Communication has an impact throughout a care plan; all recorded information helps towards the progression of the continuity of care, while delivering it throughout the healthcare sector enabling successful care delivery. Care plans are documents of evidence of the care agreed and the arrangements made by professionals who deliver the care. It provides stability to patients and professionals in connection to any medical intervention between those involved ensuring a secure environment so delivery of care can continue (Barrett et al, 2009:13-14). Recognising the impacts these principles have on a care plan are standard but the acknowledgment of their impact become relevant throughout maintaining.

Maintaining a care plan is a fundamental process established by reviewing and audits. Using these methods to maintain a care plan is essential, as it is an ongoing process to protect the welfare of patients. Reviewing and auditing can instigate the cause for professionals to look into a care plan further. Audits of records allows professionals to determine how well policies are implemented within a care environment and how standards of care delivery are set. This helps establish best practice in nursing records and helps to reduce any risk towards the patient safety, which can arise from poor record keeping (Griffiths et al, 2007:1324-1327). Information recorded draws attention upon the needs of the patient. If a patient was continually complaining of chest pain, this would alert nurses and doctors to investigate the problem and further medical intervention maybe required (Geyer, 2007:23-24). Simply doing an audit raises awareness of the need to improve practice. Regular audits on documentation have to take place to identify any necessary errors ensuring standards within healthcare facilities are ongoing and up to date.

Reviewing is essential as ongoing factual records of a patient’s health status can highlight changes in a patient’s condition. Enabling professional has to amend changes for the best interest of the patient when reviewing documentation (Brooker & Waugh, 2007:368-369). Reviews put in place help evaluate a patient’s plan of care, making sure that the care they receive is relevant to their needs at the time. The aim of reviewing documents and how maintaining them in a care plan is essential and is purposely to ensure that the safety of the patient. Reviewing documents in a care plan focuses very much on the individual receiving care. However, the persons involved in providing care to the patient play a big part in the reviewing process to ensure all care is specific to the needs of the patient (Miller & Gibb, 2007:271-271). Reviews and audits play a big part in how records maintaining documents keeps practice current and up to date ensuring the best interest of the patient, and protect the patients from any harm.

Conclusion

The purpose of record keeping is the care of the patient and is considered has a fundamental part of nursing practice. It is crucial to the well-being of the patient and the delivery of care; it also ensures that professional standards within a healthcare environment, challenging professionals ensuring the delivery of duty of care. Documents have an impact on everybody involved and written records are important and must comply within the record keeping principles and set standards to multidisciplinary teams, in turn, helping contribute to the quality of care being given. The consequences of poor record keeping are quite clear hence the requirement for medical staff to ensure that the proper procedures are undertaken. Professionals need to keep records to safe guard their patients while protecting their welfare, this highlights the need for this to remain as precise as possible throughout maintaining records while care is ongoing. Recording in documents can assist towards the continuity of care, which provides a safe stable environment for the patient. Professional’s working in a health care environment makes them aware that their workload can become very busy, it is important that they do not let this affect their need to keep records. Time should be set aside for record keeping, if records are rushed errors can develop, poor quality of records cannot show to reduce the quality of care. Good record keeping is a characteristic of a skilled practitioner and it is largely about the various forms of communication from one service to another. Records documented correctly appropriately to the NMC 2009 principle of good record keeping guidelines highlights the need of communication throughout written records. Following these principles enhances the fact of how vital record keeping is, and how record keeping is an essential method used to protect the welfare of the patient.