For most of us, record keeping is a key part of everyday practice, and maintaining proper record keeping is fundamental to effective patient care. If no record is made, the law may eventually rule that the events did not occur. Electronic record keeping helps to avoid the issue of handwriting misunderstandings and facilitates improved communication across healthcare systems.
Handheld devices enable records to be readily updated and shared while on the go. Sharing records can considerably improve communication among healthcare professionals and the system as a whole, as well as overall patient care. Modern-day record keeping also ensures patients' confidentiality.
In this article, we will explain what exactly nursing record keeping and why it is important to patient care and outcomes.
The Nursing and Midwifery Council (NMC) considers record keeping to be an essential component of the nursing profession. Record keeping is a multidisciplinary approach and a professional tool that helps to assist in the caring process. The method by which nurses and midwives keep records is typically dictated by their employers, and the NMC has acknowledged this. However, the principles of good record keeping are widely known and should reflect the essential values of individuality and collaboration.
In nursing and midwifery practise, good record keeping is critical to ensuring safe and effective patient care. It is not an optional item that can be added if circumstances allow. National programmes for the use of information and communication technology, as well as electronic record keeping, are being implemented throughout the UK. Even when the world of nursing record keeping has advanced, the use of paper record keeping is common among nurses and midwives in the UK.
Good record keeping, whether at an individual, team, or organisational level, has many important functions. Among these are a variety of clinical, administrative, and educational applications, such as:
1. Helping to improve accountability.
2. Shows how decisions related to patient care were made.
3. Supporting the delivery of services.
4. Supporting effective clinical judgement and decisions.
5. Supporting patient care and communication.
7. Making continuity of care easier.
8. Providing documentary evidence of services delivered.
9. Providing better communication and sharing of information between members of the multi-professional healthcare team.
10. It helps identify risks and enables early detection of complications.
11. Support clinical audit, research, allocation of resources, and performance planning.
12. Helps address complaints and legal processes.
The principle of good nursing record keeping applies to all sorts of records, regardless of how they are kept. Handwritten clinical notes, emails, letters to and from health experts, laboratory reports, films, text messages, and other similar documents are examples.
There are various principles of nursing record keeping, and they are as follows:
1. Handwriting should be legible and should be in a language that is easily understandable by people in your care.
2. All entries to records should be signed. When keeping written records, include the person's name and work title alongside the first entry.
3. In accordance with local policy, you must provide the date and time on all records. This should be done in real-time and chronological order, as near to the current time as possible.
4. Your records should be accurate and clear. You should also avoid recording falsified records.
5. In accordance with local policy, you must provide the date and time on all records. This should be done in real-time and chronological order, as near to the current time as possible.
6. Use your professional judgement to decide which is relevant and what should be recorded.
7. You should record details of the assessments and reviews undertaken and provide clear evidence of the arrangements you have made for future and ongoing care. This should also include details of the information given about care and treatment.
8. Identify and record all the risks or problems that have arisen and show the action you have taken to deal with them.
9. Communicate fully and effectively with your colleagues so as to ensure that they have the information they need about the people in your care.
10. Never alter or destroy any records without having permission or authorisation to do so.
11. If you need to change your own or another healthcare professional's records, you must include your name and job title, as well as sign and date the original documentation. Make certain that the changes you make and the original record are both unambiguous and auditable.
12. Where possible, it is always advisable to involve the person in your care and their family carer in the nursing record keeping.
13. Records should be readable when photocopied or scanned.
1. As a member of the nursing staff, you should be fully aware of the legal requirements and guidance regarding confidentiality and ensure your practice is in accordance with national and local policies.
2. You should be aware of the rules governing confidentiality with respect to the supply and use of data for secondary purposes.
3. Follow all the local policies and guidelines when using records for research purposes.
4. Never leave patients' medical records in public where unauthorised staff or members have access to them.
5. You shouldn't take or keep photographs of any person or their family that are not clinically relevant.
1. People in care should be informed that their medical records will be shared with other staff or agencies involved in their care.
2. Individuals in your care have the right to see their own records. You should be aware of the local policies and be able to explain them to the person.
3. Individuals in your care have the right to ask for their information to be withheld from you or other healthcare professionals, unless such action will cause harm to you or others.
4. In case you face difficulty accessing the records, you should inform someone in authority. You should keep a record of when you have done so.
5. You should not access the information of a person or their family unless it is not relevant to their care.
1. Information that can identify a person in your care must not be used or released for reasons other than healthcare without the individual's explicit consent. However, if the law requires it or there is a greater public interest, you may disseminate this information.
2. Under common law, you may reveal information if it will aid in the prevention, detection, investigation, or punishment of serious crime, or if it will prevent abuse or serious injury to others.
1. You should be aware of, and know how to use, the information systems and tools that are relevant to your work.
2. Smartcards or passwords to access information should not be shared or left open to access when you have finished using them.
3. You should take reasonable precautions to safeguard the security of your organization's nursing record keeping system and utilise it correctly, especially when dealing with confidential information.
1. It is your responsibility to stay current on relevant laws, case law, and national and local policies governing information and record keeping.
2. You must be able to effectively communicate and keep correct records, as others will rely on your records to make healthcare decisions for patients.
3. You can examine the standard of nursing record keeping and communication by auditing records and acting on the results. This will help you to identify any areas that could be improved.
These are the key principles of nursing record keeping.
Nurses Group is the leading nursing agency in the UK and gives their staff training to ensure that they have the knowledge and skill to maintain the nursing records in the various facilities they work in.
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