In any medical setting, record keeping is about more than just good handwritten clinical notes. It also applies to your emails, letters and incident reports.
It can be easy to get into bad habits and make mistakes due to high workloads and feeling the need to rush. But mistakes or shortcuts made today can cause problems in the future. Lucy Catterall, the RCN's Head of Legal (Regulatory Policy) has shared her insights. She says record keeping is no less important than the rest of your daily duties.
"Errors don’t just affect your patients," Lucy says. "You could find yourself facing disciplinary action at work and even referral to the Nursing and Midwifery Council (NMC)."
She's got three simple rules to ensure you maintain a high standard of record keeping.
Recent, readable and relevant
1. Time is of the essence
Fill out records as close to the event as possible to ensure you capture all the relevant information. If you can complete records as you go, that's ideal. Failing that, complete the record as close to any event as you possibly can. The sooner you can make your notes, the clearer your memory will be and the more you can be assured you're completing all the relevant information.
Patient records should also be an accurate reflection of the history of a patient’s care, and kept in chronological order.
2. Notes that can’t be read aren’t of use
If you’re completing a handwritten record, you’ll want to make sure it's legible. There's no point in having perfect record keeping in all other aspects if nobody can read what's been written. Slow down and make your notes purposefully.
Make sure you clearly mark the record with the date, time and a confirmation that you are the person who has logged the event. This could be by writing your name or initials. Check with your employer if you're unsure which method is used where you work.
3. Records are no place for assumptions or opinions
Lucy also warns against confusing facts and speculation. "When you're making an entry, the record needs to be kept factual. Speculation isn't appropriate for effective record keeping."
This pitfall could inadvertently influence the opinion of someone reading the entry. Jargon, slang or local vernacular should also be avoided to ensure there's no misunderstanding or confusion for whoever is reading the record.
As well as these three rules, you should keep your training on record keeping and documentation as up-to-date as possible in the same way you would ensure all your other training is maintained.
This is especially significant when any new systems are introduced at your workplace. If you're unsure whether record keeping and documentation training is available where you work, ask your employer as soon as you can.
Remember these three simple rules every time you're working on records, and you'll be on the right track.
