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Standards of Nursing and Midwifery
Nursing Standard No 2 / 2008
GUIDELINES FOR RECORDS AND RECORDS KEEPING
DEFINITION
Record keeping is the proper recording and maintenance of facts, events, history or any happening either in writing or electronic form. In general, it should be accurate, factual and well-documented. It should be easily accessible and retrievable when required
AIM
The overall aim of this guideline is to highlight the importance of records keeping and its implications for nursing practice.
GUIDELINES
This guideline will be an important tool which will ensure that nurses are in line with the code of professional practice of the Nursing Council of Mauritius. It will protect them from any breach of section (4.11), which clearly stipulates that nurses, Midwives and community nurses should keep appropriate documentation in the exercise of his/her functions and ensure that such records are accurate and factual.
IMPLICATIONS FOR NURSING PRACTICE
There is a wide consensus among all nurses that accurate record keeping and careful documentation is an essential part of nursing practice. It is also a fact that documentation of care has gained an extra significance during the recent years, particularly owing to a well-informed public and ever demanding users of health care services. Records' keeping serves many purposes:
- It protects the patients as well as those involved in giving care.
- Confidentiality about care is observed in an ethical way.
- It helps to maintain continuity of care and inform health professionals of on going care and treatment.
- It promotes and improves communication between members of health care team.
- In the context of medico-legal concern, the record serves as the legal instrument to provide “substantive evidence” as to whether care rendered did meet the standard.
- Good record keeping reflects the standard of professional practice and is a mark of the skilled of a safe practitioner.
COMPLAINTS AND LEGAL ISSUES
We live in an increasingly litigious society and patients are increasingly willing and often encouraged to complain about the care they receive. Regardless to the outcome of any complaint, accurate records are essential. Any Investigation from hospital authority, regulatory bodies or a court of law following complaints about care, will primarily use the patients' documents and other records as evidence. Hence, it is suggested that nurses must always use their professional judgement to decide what is relevant and what should be recorded. Records should be written chronologically, dated and signed by the practitioner. The approach adopted by court of law to record keeping tends to be that ”if it is not recorded, it has not been done”.
GUIDELINES FOR RECORD KEEPING
Record keeping and documentation should demonstrate:
- A full description of your assessment and the care given.
- Relevant information about the patients at any given time and what was done in response to service user needs.
- That you have understood and fulfilled your duty of care which you have taken all reasonable steps to care for the patients and any of your action or omission on your part has not compromised their safety in any way.
- A record of any arrangement you have made for the continuity of care of the patient or client.
There are a number of factors that contribute to effective record keeping. It should
- Be factual, consistent and accurate.
- Be written as soon as possible after an event has occurred, providing current information on the care and condition of the patient.
- Be written clearly in such a manner that the text can not be erased.
- Be written in such a way that any alteration or addition is dated, timed and signed and the original entry can be read clearly.
- Be accurately dated, timed and signed with the signature apposed alongside the first entry.
- Not include any abbreviation, jargon, meaningless phrase, irrelevant speculation and offensive and subjective statement.
- Be readable by any photocopier.
In conclusion, good record keeping is therefore both the product of good team work and an important tool in promoting high quality health care. Nurses are responsible for maintaining records and are accountable if documentation is not accurately completed and informative.
Special notice
Please contact the Nursing Council Nursing of Mauritius on nursingcouncil@intnet.mu if you wish to suggest changes to the content of this Nursing standard.
Final date of comment: December 2008
Expiry date : December 2009
SOURCES
Dimond, B. (2002). Legal aspects of nursing (3 rd ed). London: Longman.
Nursing & Midwifery Council. (2005). Guidelines for records and record keeping . London: Portland.
Wood, C. (2003). The importance of good record keeping for nurses . Nursing Times. 99(2) p26-27.
List of Standard in Nursing Practice
