Good record-keeping

Nurse : First of all, you must know that you have a professional and legal duty to keep records. You should thus allocate time for this documentation. Remember that without clear and accurate records for each patient, your handover to the next nursing team will be incomplete. Needless to say that this could affect the patient’s wellbeing ! A full account shows how careful, accurate and professional you are. Poorly written records can lead to doubts about the quality of your work. It can be even more serious.

Trainee : What do you mean ?

Nurse : Think of the legal aspect of record-keeping. In case of a patient’s complaint or any kind of legal proceedings, your nursing records are the only proof that you have fulfilled your duty of care to the patient. Poor record keeping can show some kind of negligence, even if you did provide the correct care. And this may lead to lose your right to practice. Do you see what I mean ?

Trainee : Yes, I think so. In short, the patient’s nursing record provides a clear account of the care planned and treatment given to the patient. It also ensures good communication as record-keeping shows that the information is correctly shared among the collegues. It also identifies problems that might have happened, and the actions taken to rectify them. But then what should go into a patient’s nursing record ?

Nurse : You should note down what nursing care the patient receives and the patient’s response to it. The records must show all relevant information about the patient at any stage. You should also indicate any other factor or event that may have affected the patient’s wellbeing.

Trainee : What could affect his wellbeing if he’s correctly taken care of ?

Nurse : It could be anything : unexpected noise, impromptu relatives’ visits, appointment for a scheduled surgery in the operation room…

Trainee : If we are unable to give a verbal handover to the next nursing team, what key elements should be written down in these records to set up continuing care of a patient ?

Nurse : You should ensure that the record begins with an identification sheet that contains the patient’s personal data: name, age, address, next of kin, carer, and so on. Date and sign each entry, giving your full name. Give the time, using the 24-hour clock system. Write in dark ink and never use a pencil as it may be erased or fade with time. On admission, record the patient’s visual acuity, blood pressure, pulse, temperature, and respiration, as well as the results of any tests. State the diagnosis clearly, but you should also indicate any other problem the patient is currently experiencing. Record all medication given to him and sign the prescription sheet. In case of surgery, ensure that the consent form is signed clearly by the patient and is included in the patient’s records. Include a nursing checklist to ensure the patient is prepared for any scheduled surgery. And finally note all plans made for the patient’s discharge.