Focus - Good record keeping

Maintaining accurate records is fundamental for accountability and professional responsibility, write Jane Twomeyand Ann Cummins

There is an increased awareness of the importance of record keeping in the Irish health sector due to the many public disclosures, enquiries and media reports. This has highlighted the need for nurses to reflect and critically evaluate their own practice and those of their employing body in relation to record management.

Accountability, confidentiality, competence and professional responsibility are the basis of nursing practice, proven through evidence in nursing documentation. 1 Nurses are held accountable by their records, professionally, ethically and legally. The nursing process incorporates record management, as many decisions in assessing, planning, implementing and evaluating patient care are based on reports from nursing observation and documentation.

Each healthcare facility may have different formats and systems of documentation, but nurses must follow standards set by local and national policies. This paper will discuss the purpose, principles, legal implications and legislation of accurate record keeping in professional nursing.

Purpose

The purpose of nursing records is to facilitate: communication between healthcare professionals and clients; care planning; quality assurance of care; educational tools for professional development; legal documentation for court cases; and healthcare analysis to monitor trends in services.1, 2 Record keeping is necessary for accurate reporting at change-of-shift, to ensure continuity of care, and to care plan conferences.3

Nursing documentation in general comprises of an admission kardex, traditional or standardised nursing care plans, flow sheets, progress notes and discharge records.3 In many Irish public hospitals, most record keeping is completed on paper and computerised documentation is not commonly utilised.

In hospital wards, computers are commonly used for accessing laboratory test results and printing patient identification labels. It has been suggested that electronic record keeping is under-used by nurses due to limited computer access and that nurses like to write in ‘freestyle’ terms as opposed to selecting pre-programmed computer-generated phrases.4 Ideal record-keeping for a patient is a ‘single, lifelong integrated multiprofessional record’, but the use of IT systems will need to be increased for this, with sufficient resources invested.5

Nurses must be aware of the risks involved in using technology and follow local risk-reduction guidelines to avoid breaches in confidentiality and errors of information in writing, storage and access to records.1, 2, 6

Principles of record keeping 

There are general principles that nurses must adhere to when keeping records. Some of the main principles include: documentation of date and time; legible ent r ies; permanency using black/blue ink, using recognised, approved terminology and abbreviations; accuracy of patient identification and events.

Facts rather than opinions are recorded; written errors should have a line through them rather than erased completeness of reporting nursing care and communication, concise reporting and all entries must be signed.1, 3, 7

Ethical principles

Nurses must be aware of ethical issues surrounding their record keeping such as maintaining confidentiality and privacy, documenting details regarding consent to treatment, and the use of patient records in research.1

Confidentiality must be maintained when discerning the sharing of patient information with colleagues, families and courts of law. Consent should never be presumed and should a patient accept or refuse a procedure it must be documented. When carrying out research, nurses must guarantee that patient rights are not infringed and ethical approval is gained.

Legal considerations

Record keeping gives proof of nursing care provided. Nursing records are used in evidence in criminal prosecution and in nursing-legal claims and so accurate, complete documentation is vital to demonstrate that standards of care were maintained, protecting the patient, nurse and healthcare institution. Nurses must document nursing actions, their rationale and communication with patients, other healthcare professionals and families.

A court case may occur years after an alleged incident, as per the Statue of Limitations, so nursing notes may be the only tool of memory recall. A legal supposition is that if care is not recorded, it was not done.1 Verbal communication at change of shift may not be effective for care planning and so written records are essential.8Education and continuous organisational support, including ongoing seminars and regular supervision, can increase the quantity and quality of nursing documentation in an acute hospital setting.9

Legislation

Nurses need to be aware of lrish legislation governing record management and patient rights to access records. Patients are the owners of their health records, they have the right to access these and decide who shares in that information. Nurses have an obligation to ensure privacy.6

Some Irish legislation of significance to nursing includes the Data Protection Acts 1988 and 200310 and the Freedom of Information Acts 1997 and 2003.11 Both acts highlight that individuals have the right to personal information being kept securely. Individuals have the right to access their information by making an access request, the right to rectification or deletion of inaccurate information, and the right to prevent data being used for certain purposes, such as research.

Irish inquiry recommendations

In separate inquiries, Harding Clark (2006)12 and O’Neill (2006)13 revealed inadequacies in nursing record-keeping practices. They noted that record keeping was not comprehensive, with little information or evidence of care planning and interventions, amid lack of policy concerning documentation. In their reports, entries lacked detail of times, dates and signatures. Documentation errors were incorrectly managed and there was deliberate interference with records.

In addition, storage of and access to records was criticised as many patient files disappeared, leading to time wastage, decreased evidence load and reduced transparency. Recommendations include accurate, current, legible and signed documentation, regularly audited by an objective party and the use of IT systems for easy access of information, with patient records in a standardised format.12

Further recommendations are that nurses should have specialist education and clinical updates in professional nursing issues such as record keeping, incident reporting, and scope of practice and code of professional conduct.13 Both recommended increased standards of manual record keeping with the introduction of ancillary IT systems.12, 13

This paper concludes that record keeping is a dynamic and vital part of the nurse’s role. Nurses are accountable to their patient, themselves, the public, their employer and supervisory body, therefore ensuring best practice by partaking in ongoing record-keeping education is productive for patient safety. It is also important as a defensive mechanism from litigation.

Records should be subject to quality control inspections and regular audits so errors can be highlighted and educational interventions formed. Conflict of values arise when using IT and standardised documentation can save time, but nurses may favour documenting personalised care. Literature highlights that the future of record keeping may be in expanding the use of computer technology but adequate resources must be invested to make this successful. In the present economic climate, it is likely that current documentation practices will continue and so best practice must be encouraged with patient safety at the forefront.

Jane Twomey is a fourth-year nursing student in BSc Nursing Integrated Children’s and General Programme and Ann Cummins is a lecturer practitioner in Diploma in Integrated Computer Applications

References

  1. An Bord Altranais (2002). Recording Clinical Practice Guidance to Nurses and Midwives Dublin: ABA
  2. Frank-Stromborg, M., Christensen, A. and Elmhurst, D. (2001a). Nurse Documentation: Not done or worse, done the wrong way – Part I Oncology Nursing Forum 28 (4) 697-702
  3. Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of Nursing; Concepts, Process and Practice (7th ed.) New Jersey: Pearson Prentice Hall
  4. Ballard, E.C. (2006). Improving Information Management in Ward Nurses’ Practice Nursing Standard 20 (50) 43-48
  5. Owen K. (2005) Documentation in nursing practice. Nursing Standard 19, 48–49
  6. International Council of Nurses (2008). Health Information: Protecting Patients Rights; Position Statement Geneva: ICN
  7. Dougherty, L. and Lister, S. (2004). The Royal Marsden Hospital Manual of Clinical Nursing Procedures (6th ed.) Oxford: Blackwell Publishing
  8. Dowding, D. (2001). Examining the effects that manipulating information given in the change of shift report has on nurses’ care planning ability Journal of Advanced Nursing 33 (6) 836-846
  9. Bjorvell, C., Wredling, R. and Thorell-Ekstrand, I. (2002). Long-term increase in quality of nursing documentation: effects of a comprehensive intervention Scandinavian Journal of Caring Sciences 16 34-42
  10. Office of the Data Protection Commissioner (2009). Data Protection Acts 1988 and 2003; A Guide to your Rights Portarlington: Office of the Data Protection Commissioner
  11. FOI Central Policy Unit (2004). Short Guide to the Freedom of Information Act 1997 and Freedom of Information (Amendment) Act 2003 Dublin: Department of Finance
  12. Harding Clarke, M. (2006). The Lourdes Hospital Enquiry; An inquiry into peripartum hysterectomy at Our Lady of Lourdes Hospital, Drogheda Dublin: Stationary Office
  13. O’Neill, D. (2006) Leas Cross Review Dublin: Department of Health and Children
Focus - Good record keeping

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