Record Keeping and Documentation
Published: 27 May 2018
Published: 27 May 2018
An accurate written record detailing all aspects of patient monitoring is important, not only because it forms an integral part of the of the provision of care or nursing management of the patient, but because it also contributes to the circulation of information amongst the different teams involved in the patient’s treatment or care.
In a legal sense, documentation and record keeping is also there for the protection of the nurse or healthcare professional.
A well-kept record can protect the practitioner in instances where the legal defence of their actions is required. Documentation also ensures a matter of professionalisation and proof of the improvement of practices.
You’ll be expected to be able to comply with whatever requirements your employer or organisation sets for record-keeping. That means you’ll need to:
Components of a patient’s records include:
Some key factors underpin good record keeping. The patient’s records should:
(Jevon 2012; RCN 2017)
Poor record keeping hampers the care that patients receive and makes it difficult for healthcare professionals to defend their practice.
The most common deficiencies in record keeping include:
Record keeping is a tool for professional practice and one that should help the care process. It is not separate and not an optional extra to be fitted in if circumstances allow.
A record should be made as soon as possible after the patient is seen or the procedure is complete. It’s important that accurate record is made in the patient’s notes and should include interventions and any response to the interventions.
The patient’s records are occasionally required as evidence before a court of law, or to investigate a complaint at a local, organisation level.
Sometimes records may be requested by professional governing bodies when investigating claims related to misconduct (NMC 2010).
Therefore, you must take care about what you write. Not only will you be asked to formally explain your records in the event of, for instance, a complaint from a patient/client, but registered nurses have both a professional and legal duty of care.
It is therefore critical to keep up-to-date with the legal requirements and best practices of record-keeping, proving that:
A registered nurse is accountable for any delegation of record keeping to members of the multi-professional team who are not registered practitioners, such as assistant practitioners (AP), care assistants and nursing students (Jevon 2012).
As with any delegated activity, registered nurses should:
When caring for a patient, it is important to ensure good record keeping to promote patient care and better communication. Good record keeping is a product of good teamwork and an important tool in developing high-quality healthcare and reinforcing professionalism within nursing.
Question 1 of 3
True or false? Original entries in patient records should be legible, even if changes have occurred.
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Lydia Nabwami is registered nurse who has worked in various healthcare settings including cardiac ward, cardiac critical care unit (ITU), general ITU, A&E department, nursing homes and community nursing. She uses her experience as a RN to write well-researched content that helps to attract and motivate audiences. Lydia is also a freelance writer for hire with specialisation in health writing and has helped numerous companies with their content needs. Her work has appeared on sites such as Caring Village, Reachout, Lisa Nelson RD and more. When she isn’t writing, you can find her listening to motivational speeches, keeping active or playing with her two daughters. Contact Lydia or visit her website at Lnwritingservices.co.uk for more information on her services. See Educator Profile