In 2009 the Nursing and Midwifery Council ( known as the NMC ) issued revised guidelines entitled: Record Keeping: Guidance for Nurses and Midwifes ( 2009 ) . Harmonizing to this guideline, suited quality records means information demands to be legible ; seasonably ; relevant ; consistent ; accessible, nonsubjective ; factual and complete. This guideline states that “ Good record maintaining is an built-in portion of nursing and obstetrics practise, and is indispensable to the proviso of safe and effectual attention. ” ( NMC 2009 ) . This essay will see four of the rules from the NMC Record Keeping: Guidance and Midwifes ( 2009 ) . Further, based on these four rules, this essay will concentrate on the impact on record maintaining in a patients attention program and will so travel on to see how good record maintaining is maintained in relation to a patients attention program. Mentions will be provided in support of the points made in this essay and will besides be comparative to what the author has observed in practise arrangements. Finally, decisions will be drawn which summarises the points associating to this essay and will see the grounds to pull on its decision.
The first point selected is point one which states that “ Handwriting should be legible ” ( NMC 2009 ) . Sokol D and Hettige S ( 2006 ) mentioning Gakhar H, Sawant N, Pozo J. Audit of the discernability of operation notes. In: Royal College of Surgeons of Edinburgh Audit Symposium 2005. Edinburgh: RCS Ed, 2005 province that three sawboness audited the discernability of 40 indiscriminately selected operative notes from an orthopedic ward in a big British infirmary. Two nurses, two physical therapists and two medical house officers were asked to rate the discernability of the notes as ‘excellent ‘ , ‘good ‘ , ‘fair ‘ , or ‘poor ‘ . Merely 24 % were rated ‘excellent ‘ or ‘good ‘ and 37 % were deemed ‘poor ‘ . This research suggests a really high per centum is the consequence of illegible script, which in bend could propose that attention could be impacted on in over a 3rd of the patients. McGeehan R ( 2007 ) mentioning Griffith ( 2004 ) suggests that the criterion of script is besides portion of a nurses responsibility of attention towards patients. If harm befalls a patient because co-workers were non able to read a nurses script, so they may be accused of liability in carelessness. It should be remembered that discernability includes the signature of the individual doing the entry. McGeehan R ( 2007 ) mentioning Griffith ( 2004 ) . The author of this essay, while on arrangement, discovered illegible script in the early old ages of a chronology which formed portion of a patient ‘s record. This led the author to seek elucidation of what was stated, some words could non be read and the original signer had left many old ages ago, this was but one negative impact of illegible script and fortuitously in this instance the entries where dated a few old ages back but could hold lead to jobs at the clip. Illegible handwriting on a attention program can look to be inaccurate and these inaccuracies can take to holds in transporting out the proviso of attention harmonizing to the attention program along with lending to mistakes. Other impacts are that medicine could be issued falsely, people can do wrong premise, wrong attention could be implemented and patients could go baffled and agitated by non being able to read their attention program. Mistakes made due to illegible script can hold fiscal and legal issues besides. If a instance goes to tribunal so the first things looked at are the records, if script is illegible so the author and their professionalism can be discredited from the oncoming. Culley F ( 2001 ) suggests that “ Once a wont, it becomes 2nd nature to compose good, voluminous records. ” Nursing & A ; Residential Care, August 2001, Vol 3, No 8 mentioning Chapman N ( 1997 ) A medical examiner ‘s position on the maintaining of medical records. Health Care Risk Report April: 1 This suggests a positive impacts of good record maintaining in a patients attention program, if consistent it becomes 2nd nature and becomes a theoretical account to others. A good illustration of this was witnessed by the author of this essay on arrangement when their wise man was showing how they filled in some subdivisions, they could show that they ever filled in the inside informations the same manner systematically, it had become that ‘second nature ‘ to make it right. The purpose of good record maintaining is to guarantee that co-workers have the information from the records to cognize what attention and intervention has taken topographic point, what is presently taking topographic point and the hereafter attention ” Dimond B ( 2005 ) . A attention program should be legible for co-workers and the patient to be allowed to pull out this information easy and this can non be done if non legible. Good legible script should demo a nurses professionalism, people should be able to clearly read what is written, by whom and when and the attention program should look accurate as a consequence in bend bettering the attention of the patient. In order for legible script to be maintained in a attention program, a consistence should be shown. Good illustrations of attention programs should let for discernability, an index of signatures at the beginning of each attention program including name, place and your signature. If diffident about what any script says a nurse should ever seek lucidity. Highlight any hapless script or possible mistake due to illegible authorship. The patient should experience comfy discoursing illegible script and nurses should promote feedback without reverberations. Highlight any signatures that are non on the index. Double cheque anything you are diffident about in a patients attention program. “ Regular audit is indispensable to place mistakes in record maintaining and to keep sensible criterions ” Dimond B ( 2005 ) This suggests that an audits should be carried out and that they can place at an earlier phase any tendency of hapless record maintaining and action consequently.
The 2nd point selected is point five which states that “ records should be factual and non include unneeded abbreviations, slang, meaningless phrases or irrelevant guess ” . ( NMC 2009 ) . Care programs are used non merely to pass on with and work with the patients but to besides let staff to pass on expeditiously and enter the attention that has been carried out. It is hence of import to utilize simple clear, factual and relevant information while entering information in a manner that everyone understands. “ Supplying safe and high-quality patient attention is dependent upon effectual communicating between wellness attention professionals, patients, and patients ‘ households ” . Schyve P M J Gen Intern Med. 2007 November ; 22 ( Suppl 2 ) : 360-361. Published on-line 2007 October 24. Department of the Interior: 10.1007/s11606-007-0365-3. hypertext transfer protocol: //www.ncbi.nlm.nih.gov/pmc/articles/PMC2078554/ accessed 14th Jan 2010.
Information included in the attention program should be based on the facts involved, illustrations being, what was really seen, what really happened. The difference in fact from a nurse ‘s sentiment should be clear and distinguished when information is recorded in a attention program.
Many patients will non understand nurse slang, abbreviation or proficient information written in their attention program. Griffith R ( 2007 ) states that the enticement to utilize slang and abbreviations as a signifier of professional stenography is obliging for busy wellness professionals. The hazard of miscommunication additions dramatically by utilizing this stenography. Griffith R Nurse Prescribing 2007 Vol 5 No 8 hypertext transfer protocol: //www.internurse.com.ezproxy.stir.ac.uk/cgi-bin/go.pl/library/article.cgi? uid=27147 ; article=NP_5_8_363_366 Accessed 19/01/10. The impact of this is that it is non patient centred attention and contravenes the NMC codification which states that ‘ You must portion with people, in a manner they understand, the information they want or need to cognize about their wellness ‘ NMC ( 2007 ) . One nurse ‘s abbreviations may differ from another and abbreviations should be avoided where possible but if necessary an index of abbreviations should be supplied to the patient and form portion of their attention program. A hapless illustration of this was witnessed by the write of this essay late on arrangement when NHS 24 sent a contact sheet to the arrangement to go to a patient ; the contact sheet was full of abbreviations with no index included as a pupil nurse the author was unaware of what some of these meant and had to inquire for aid. A patient requesting to see their notes would besides endure the same job.
Wood C ( 2003 ) states that to compose full descriptions would impact on the clip taken to come in records. However, he besides highlights the dangers where abbreviations could intend different things to patients and staff. This examines the statement that nurses do n’t hold clip to finish accurate records but prompts that an in agreement list, which should be audited on a regular footing be attached to the attention program. A factual attention program that is written in a relevant and easy understood mode that promotes clear communicating should be maintained. This so should let others particularly the patient, to pick up at any point and be able to follow their attention program.
The 3rd point selected is point 13 which states that “ the linguistic communication that you use should be easy understood by the people in your attention ” . NMC ( 2009 ) . Each patient is alone when it comes to linguistic communication that they can understand ; they each have their ain degree of communicating and apprehension. Cully F ( 2001 ) Suggests that in supplying sufficient information to let patients to do informed determinations is an indispensable constituent of the responsibility of attention, and it supports the ethical rules of individualism. This information needs to be provided in a patients attention program in such a mode that there leaves no uncertainty to the patient.
Dougherty L and Lister S ( 2008 ) Page 23 remark that attention programs should be written wherever possible with the engagement of the patient, in footings that they can understand including relevant nucleus attention programs that are individualised, signed, dated and timed This suggests that composing the attention program with the patient allows them to derive the information that they may necessitate about their status and the intervention options in a mode that allows the patient to understand the linguistic communication used, on a degree that meets their communicating demands. An first-class illustration of this was witnessed by the author of this essay on arrangement. It involved their wise man sitting with a new occupant and making their attention program from the beginning, several times the occupant requested what something meant and the wise man explained clearly and rewrote subdivision of the attention program to suit the occupants understanding. Ambiguity may besides be an issue that impacts on a patients attention program, “ statements may be interpreted otherwise ” Dimond B ( 2002 ) . She suggests that illustrations like ‘had a good twenty-four hours ‘ may intend several things to a patient for case, they may hold slept all twenty-four hours or may hold been awake all twenty-four hours. These types of generic statements do non supply the patient with the information they need. The author of this essay witnessed statements like ‘settled forenoon ‘ and ‘slept good ‘ on a recent arrangement ; once more these are general footings which should be avoided. A Care program written with the patient should besides hold clear and concise direction, this should be every bit specific as possible leting the patient to besides be involved in a clear mode, co-workers and other professions may be cognizant of what a statement may intend but the patient may non. ‘You should besides compose your instructions harmonizing to who they are intended for. For illustration, composing in the attention program to detect for marks of redness sing a lesion is non specific plenty, as non everyone will cognize what these marks are. Ideally, you should compose: ‘ … such as increased hurting, swelling, inflammation and heat. ‘ Wright K ( 2005 ) . In keeping clear linguistic communication the patient ‘s well-being is critical and if the patient is informed and understands what is written in their attention program so that contributes to their well-being. Language in a attention program should be clear and unambiguous and audits should be carried out on a regular basis. “ Audited accounts are a good method of bettering and prolonging a high criterion of record maintaining. The Audit Commission ( 2002 ) , in a reappraisal of wellness records, found that subjecting records to scrutinize cuts down dramatically on mistakes and hapless criterions. ” Griffith R ( 2004 ) British Journal of Community Nursing, 2004, Vol 9, No 3.
The 4th and concluding point selected is point two which states that “ all entries to records should be signed. In the instance of written records, the individual ‘s name and occupation rubric should be printed alongside the first entry ” . NMC ( 2009 ) . Signatures are really of import as a nurse has a responsibility to transport out the attention program and later use their signature, this helps to give grounds of their engagement and to show that their responsibility of attention has been carried out. Griffith R ( 2004 ) suggests that attention programs require to be detailed exhaustively and be sufficient plenty to exhibit that anyone responsible for entering entries in the attention program has discharged their responsibility of attention. This highlights that as a nurse discharges their responsibility they are subscribing and accountable for the actions and information entered into the attention program. This non merely impacts on other professions awareness of acknowledged item in the attention program but besides allows the patient to see that their attention program is being carried out. Dimond B ( 2005 ) suggests that it is indispensable that an writer of an entry in a wellness record is clearly and easy identifiable. An illustration of this being of import would be to reach the signer to discourse the patient or the attention in their attention program. Griffith R ( 2004 ) British Journal of Community Nursing, 2004, Vol 9, No 3. This leads to the importance of besides guaranting that the nurse ‘s name and rubric is printed on their first entry of each page, which allows the patient and other professions to non hold to invariably flick through the attention program to place the signer. There are many cases of hapless practise when coming to subscribing an entry, in a instance highlighted in the NMC Fitness to Practise Annual Report 2004 -2005 sing a nurse working on the forenoon displacement who had received a hand-over from the respondent nurse after dark responsibility. Subsequently, when she went to administrate the forenoon medicine, she saw that none of the drugs at 10pm had been signed for in the medicine disposal record. This illustration of hapless record maintaining could potentially hold lead to farther hold in the execution of the attention program and possible the patient enduring injury, this is hapless practise and does non back up the bringing of the service to the patient. In keeping this process all signatures should be legible and contemporary to the record entry. Good illustrations of this were witnessed by the author of this essay on arrangement as their wise man would compose non merely their signature at the point of action but besides day of the month and clip it. A clear print of the name and place should be on the first entry of each page of that peculiar individual composing the entry. A good illustration of this was witnessed by the author of this essay several times when their wise man carried out this process routinely and without fail, this led to the attention program signatures being identified easy. A Nurse is accountable for their attention and the right signature is a factor in taking duty and understanding the relevancy of this action. It should be noted that All NHS employees are responsible for any wellness records which they create or use. This duty is established and defined by the jurisprudence ( Public Records ( Scotland ) Act 1937 ) .
Therefore in decision the effects of hapless record maintaining should advance the maintaining of a good criterion of relevant record maintaining in line with the NMC ( 2009 ) record maintaining counsel. In the NMC Fitness to Practise Annual Report 1st April 2008 to 31st March 2009, the investigation commission received one thousand seven hundred and fifty nine new instances of ailment referrals. Classified as allegations of failure to keep equal records was 8.52 % which was one hundred and 50 records. It would look sensible to propose that this sounds rather a low figure but the impact of the possible effect of even one record are significant. There are legal facets, “ Mistakes and losing information in records are common and are a major contributory factor in medical mistakes and hapless clinical attention, taking to ailments and medical carelessness instances. ” E Health Insider Sept 2007citing RCP. hypertext transfer protocol: //www.e-health-insider.com/news/3022/rcp_launches_generic_record-keeping_standards Accessed 18/1/10
A nurse should bear in head that any entry made in a attention program can be scrutinized under a tribunal of jurisprudence. They have an answerability to keep their records as a record is considered to be a legal papers because it contains information about the attention that has been planned and delivered to a client or patient and because it may be requested by a tribunal of jurisprudence ( Dimond, 2002 ) . Dimond B ( 2002 ) . Legal Aspects of Nursing. Third Edition. London. However, good record maintaining is non simply sing a nurse protecting themselves from legal proceedings but good record maintaining in respects to a patients attention program is foremost aimed at bettering a patient ‘s attention.
McGeehan R ( 2007 ) states that ‘records should supply a complete patient journey ‘ McGeehan R ( 2007 ) Best Practise in record- maintaining. Nursing Standard. 21, 17, 51-55. The suggests that the attention program of the patient is at that place for the patient to follow and understand at a degree that they feel involved in, and besides for co-workers and other professions to pick up a attention program and cognize precisely the program involves and go on their attention in line with it. The hazards to a patient can be considerable the Audit Commision 2009 stated that Auditors identified issues associating to the quality of records at 80 per cent of trusts ( England ) and, in one instance, the figure of records classified as insecure to scrutinize represented over 16 per cent of the sample reviewed. This committee farther states that this presents non merely fiscal hazards but more significantly raises concerns from a clinical and patient safety position. Bettering the quality of records will assist to better the quality of attention.
Audit Commision 2009
hypertext transfer protocol: //www.audit-commission.gov.uk/SiteCollectionDocuments/AuditCommissionReports/NationalStudies/20090827pbrdataassuranceframework0809rep.pdf
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Ethical facets should be promoted in that a nurse has a responsibility of attention to the patient and themselves, advancing professionalism and attention. The Audit Commission ( 2002 ) , in its reappraisal of wellness records, found that subjecting records to scrutinize cuts down dramatically on mistakes and hapless criterions. Nurses should be able to measure and scrutinize their records officially and informally, to reexamine how the record reflects the attention they give even before the content is read. McGeehan R ( 2007 ) . Regular audits should be carried out non merely for self assessment intents but to besides foreground hapless practise and should affect all relevant attention squad members. ‘Part of a nurse ‘s professional duty is to inform a senior staff member of any incidences of hapless record maintaining. McGeehan R ( 2007 ) Best Practise in record- maintaining. Nursing Standard. 21, 17, 51-55. On a recent arrangement the author of this essay witnessed an audit being carried out and this was routinely done each month, the lessons were learned from these audits and hapless record maintaining ha become minimum as a consequence. Proper record maintaining in a patients attention program is an of import facet of nursing A good attention program is required for good pattern. Healthcare is now a multidisciplinary procedure and in order to keep efficient intervention for patients it is of import that a nurse, the patient and other professions have entree to good quality patient records which are reviewed on a regular basis to guarantee that the service is kept to a professional criterion and keep patient attention and safety.