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A guide to case notes and record-keeping

If it isn't recorded, it hasn't happened. This is a useful maxim for all healthcare practitioners.

This article aims to provide information on documentation and recording, to understand why records are kept, the standard to which records should be kept and some of the legal issues relating to record-keeping for nurses in the general practice setting.

The Department of Health1 defines a care record as a paper or electronic-based record which contains information or personal data pertaining to a person's care. Best practice recommends that patients benefit from records that promote communication and high-quality care. The Essence of Care1 benchmarks this to:
    - Patients being able to access their care records in a format that meets their needs.
    - Patients having a single, life-long multi-professional and multi-agency (where appropriate) care record which supports integrated care.
    - Patient care records demonstrating that their care is evidence-based.
    - Patient care records being safeguarded.

This view is supported by the Nursing and Midwifery Council (NMC)2 who state good record-keeping is an integral part of nursing 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. Prideaux3 makes the point that record-keeping details the patient's journey through the healthcare process and can protect the accountability of staff who deliver that care. Wood4 identifies that one of the most common causes of legal claims arises from a breakdown in communication between health professionals particularly related to incomplete or inadequate records.

All patients' records should not only provide a clear account of a particular episode of care but also a comprehensive and concise record of what has occurred.5 Good records put the patient at the centre of care, track clinical decision-making and care goals, allow audit of practice and protect clinicians against clinical negligence claims. The converse of this is that poor record-keeping increases workload, undermines patient care and makes individuals vulnerable to legal and professional problems. Specific issues with poor record-keeping relate to the quality of information recorded, this can be seen in the use of words such as adequate or reasonable. There is no way to quantify these remarks and therefore they are open to misinterpretation. The use of an abbreviation such as DOA could mean both date of admission or dead on arrival, potentially a devastating message to pass on. While a good description of facts is essential, health professionals should stay away from making value judgements about a patient's personal circumstances.

Guidelines for practice
For nurses, guidance on record-keeping is issued by the NMC,1 and other professions have similar guidance.6 It should be noted that these are guidance documents and there is no one way to record information or one rule to define what to record.3 Review of the literature highlights the following principles:
    - Local standards and professional judgement dictate the frequency of entries, but a minimum would be after each point of contact and should apply to all practice staff.
    - Records need to follow a logical sequence with clear checkpoints and goals and answer the question “if I were caring for this patient for the first time, what would I need to know?”
    - It is important to document those things not done, with a rationale, as well as those done, especially if the action deviates from an agreed protocol.
    - Registered nurses are not accountable for the entries made by student nurses or the health care assistant, however those staff do need to have received training on record-keeping and practice standards.7
    - Do not mistake assumption for fact. If you didn't see it, hear it or do it, you don't know it. State the patient reported that, and always record patient and relatives' comments and requests.
In addition the NMC1 recommends that patient records should:
    - Be factual, consistent and accurate.
    - Be written as soon as possible after an event has occurred.
    - Provide current information on the care and condition of the patient.
    - Dated, timed and signed with the signature printed alongside the first entry.
    - Be written in terms the patient can understand, and when possible with the involvement of the patient.
    - Not include abbreviations, jargon, meaningless phrases, irrelevant speculation or offensive subject terms.
    - Be readable on any photocopies - black ink is preferable.
    - Alterations must be crossed out with one line, dated and signed, ensuring the original entry can still be read.

What happens when things go wrong?
The NHS Litigation Authority8 reports that there were 9,143 claims against the NHS in 2011-12 with an expenditure of £1,095.3 million and legal costs of £182,735. Good record-keeping can protect both individuals and their employers.
Careful and accurate records may assist health professionals in defending claims of negligence. It is important to record the reasons for decisions as well as the actual intervention undertaken. The way to evidence this breach is through review of the patient's record. This review is often the deciding factor in the decision to proceed.9 If records are poor, there is an inference of poor practice and a claim may arise. There are limitations10 to the time the complaint may occur. There is also a cost to individual health practitioners with potential referral to the regulatory body.4

Another key area is around the safeguarding of patient data.11 Nurses need to remember who is able to access records1,11 and obtain consent from patients to share data. In busy clinical environments there is also a need to monitor potential breaches in confidentiality4 —curtains are not a barrier to sound. This is also important when using text messaging services to inform patients of appointments or results.4 Increasingly, social media sites can compromise patient confidentiality.

Good record-keeping enhances patient care, giving a clear and purposeful record of both care given and care planned, so that all health professionals can achieve the best outcomes for their patients.

1.        Department of Health.  Essence of Care 2010; Ref 14641. Accessed August 2012
2.        Nursing and Midwifery Council - NMC guidelines for records and record keeping 2009.
3.        Prideaux A. Issues in nursing documentation and record-keeping practice. British Journal of Nursing 2011;20(22):1450.
4.        Wood S. Effective record-keeping. Practice Nurse 2010 Feb 26;39(4):20-23
5.        Pirie S. Legal and professional issues for the perioperative practitioner. The Journal of Perioperative Practice 2012;22(2):57-62.
6.        Royal College of Physicians Generic medical record keeping standards 2007 Publication Code 15615 accessed August 2012
7.        Hand T For the Record Practice Nursing 2012 23(4) 170
8.        NHS Litigation Authority Annual Reports and Accounts 2012 accessed August 2012
9.        Glasper A. Improving record keeping: important lessons for nurses. British Journal of Nursing 2011;20(14):886.
10.        Limitations Act 1980 Access August 2012
11.        Information Commissioner's Office The Guide to Data Protection 2012 ActData accessed August 2012
12.        Royal College of Nursing - Legal Advice for RCN members using the internet. 2009 Publication Code 003557