Records & Record Keeping

NMC Guidelines & Publications

Ensuring Good Record Keeping Good record keeping is an integral part of nursing and midwifery practice, and is essential to the provision of safe and effective care. It is not an optional extra to be fitted in if circumstances allow. (NMC 2009)

When Do We Record Information? As soon as possible after an event has occurred Studies in the UK and USA show that 80% of detail surrounding an event is ‘lost’ after the first hours The approach to record keeping which courts of law adopt is that ‘if it is not recorded, it has not happened’

Important Functions. Improve accountability Shows how decisions related to patient care were made Supports the delivery of services Supports effective clinical judgments and decisions Supports patient care and communications Makes continuity of care easier Documentary evidence of services delivered Promotes communication and sharing of information Helps to identify risks Supports clinical audit, research, allocation of resources and performance planning, and Helps to address complaints or legal processes.

Types of Records Kept Handwritten clinical notes s Letters to & from other Health Professionals Laboratory Reports X-rays Printouts from monitoring equipment Incident reports and statements Photographs Videos Tape-recordings of phone conversations Text messages

Principles of Good Record Keeping Legible Handwriting All entries should be signed with name and job title printed alongside first entry Date and time on each entry Accurate with clear meaning Factual without abbreviations, jargon, meaningless phrases or irrelevant speculation Relevant Evidence of planned future and ongoing care

Identify risks/problems and action taken Communicate effectively Should not be altered or destroyed without authorisation Alterations should be signed with job title, dated and auditable Patient/Carer involved in process where appropriate Easily understood language Be photocopied and scanned No coded expressions or abbreviations You should not falsify records

Confidentiality Fully aware of legal requirements and guidance regarding confidentiality, ensuring your practice is in line with national and local policy. Awareness of the rules in respect of supply and use of data for secondary purpose Follow local policy when using records for research purposes You should not take or keep photos of any person or their family that are not clinically relevant

Confidentiality You should not discuss the people in your care in places where you might be overheard. Nor should you leave records, either on paper or on computer screens, where they might be seen by unauthorised staff or members of the public (NMC 2009)

Access People in your care: Should be told health records may be seen by other people or agencies involved in their care Have a right to ask to see their own health records (Freedom of Information Act (Scotland) 2002) Have a right to ask for their information to be withheld from you or other health professionals You should report problems relating to access or record keeping to someone in authority You should not access records of any person, or their family to find out personal information that is not relevant to their care.

Storage of Records Where should records be stored? Can notes be kept by the patient’s bed? What about storage in a client’s home?

Disclosure Information that can identify a person in your care must not be used or disclosed for purposes other than healthcare without the individual’s explicit consent. However, you can release this information if the law requires it, or where there is a wider public interest. Under common law, you are allowed to disclose information if it will help to prevent, detect, investigate or punish serious crime or if it will prevent abuse or serious harm to others.

Information Systems You should be aware of, and know how to use, the information systems and tools that are available to you in your practice. Smartcards or passwords to access information systems must not be shared. Similarly, do not leave systems open to access when you have finished using them. You should take reasonable measures to check that your organisation’s systems for recording and storing information, whether by computer, , fax or any other electronic means, are secure. You should ensure you use the system appropriately, particularly in relation to confidentiality.

Personal and Professional Knowledge and Skills You have a duty to keep up to date with, relevant legislation, case law and national and local policies relating to information and record keeping. You should develop, your ability to communicate effectively within teams. The way you record information and communicate is crucial. Other people will rely on your records, especially during handover, referral and in shared care. By auditing records and acting on the results, you can assess the standard of the record keeping and communications. This will allow you to identify any areas where improvements might be made.

Retention of records Who owns the records? What is the registrants responsibility? How long can records be retained? Are there official guidelines?

Division Manuals Policy Manual Infection Control Moving & Handling Health & Safety I.V Therapy Research COSHH Procedure Manual Religions & Cultures Nutrition Pain Palliative Care Care of the Dying and Bereaved

QUESTIONS ?

Freedom of Information (Scotland) Act 2002 Should all information be made available? What are the main requirements? Do people have to pay for information? What do I have to do? Is there a time limit? What if an applicant is not satisfied?

Delegation of record keeping You must establish that anyone you delegate to is able to carry out your instruction You must confirm that the outcome of any delegated task meets the required standards You must make sure that everyone you are responsible for is supervised and supported NMC2008

Legal matters and complaints As a registered nurse or midwife, you have both a professional and a legal duty of care. Your record keeping should therefore be able to demonstrate: A full account of your assessment and the care you have planned and provided Relevant information about the condition of the patient at any given time and the measures you have taken to respond to their needs

Legal matters and complaints Evidence that you have understood and honoured your duty of care, that you have taken all reasonable steps to care for the patient and that any actions or omissions on your part have not compromised their safety in any way. A record of any arrangements you have made for the continuing care of a patient.

Audit Plays a vital part in ensuring the quality of the care that is delivered and this applies equally to the process of record keeping Risk management Promotion of quality Identifies areas for improvement Staff development

Division Manuals Policy ManualProcedure Manual Infection ControlCOSHH Moving & Handling Religions & Cultures Health & Safety Care of the Dying and Bereaved NutritionIV Therapy ResearchPain Palliative Care