This site is intended for health professionals only

Record keeping in practice: getting it right

Many nurses find it difficult to meet the requirements for record keeping and documentation. Rita Newland describes the essential attributes of a record that is written to a high standard and outlines strategies for improving the clarity of the content of records

Rita Newland
MSc BSc PGDip RGN RM HV DN
Lecturer
Public Health, Primary Care and Food Policy Department
City University London
Professional Officer
Unite/CPHVA

All nurses have a professional and legal responsibility to provide accurate and complete records for the patients in their care. Despite this, many nurses find it incredibly difficult to meet the requirements for record keeping and documentation that are outlined by the Nursing and Midwifery Council (NMC).(1) It therefore remains one of the most common reasons for being removed from the Nursing and Midwifery Register (see Box 1).(2,3)

[[nip44_box1_56]]
 
This article will outline some of the reasons why this is the case and will suggest strategies to help nurses overcome the barriers to effective and efficient record keeping and documentation in practice.

Record keeping standards
Achieving a high standard of record keeping practice is one of the fundamental lessons learnt during nurse education programmes and one that should be
regularly revisited during a nurse's career. However, the literature states that nurses' records often fail to achieve the required standards.(2-4) In explanation, a record that is written to a high standard has several visible features as outlined in Box 2. Records that do not contain these features are considered to be substandard and potentially place the client/patient at risk of receiving inadequate or incorrect care and leave the nurse vulnerable to allegations of neglect and misconduct.
These features ensure that the record is easy and quick to read and that it is possible to identify information as fact or supposition. It is important to appreciate that nurses record information in different ways, but different methods do not necessarily produce records of a high standard.

[[nip44_box2_56]]
 
One example of this is the use of abbreviations, often seen as a time-saving mechanism. However, the profession does not have an agreed glossary of abbreviations, so there is a danger that information will be misinterpreted because the abbreviation may mean one thing to one group and something different to another. For example, HV could mean home visit or health visitor, and may be used for both meanings in the same record. The record in this situation would fail to be a source of information sharing and could in fact cause great danger to the client/patient if the reader misinterpreted the content. Therefore a high standard record should not contain any abbreviations.
It is also important to note that a high standard record is not necessarily one in which there are no mistakes - it is accepted that mistakes will occur when recording information. However, a high standard record is one in which all mistakes have been clearly identified by a single line which is dated and signed by the person making the alteration. Once this process is complete it is important that the reader is able to see the original entry and recognise that an alteration has been made.(1)
There are many reasons why nurses do not achieve a high standard of record keeping in practice, such as a lack of time, the need to balance the requirements of record keeping with the demands for hands-on-care, and the belief that the information within the record remains dormant because no one ever reads it (see Box 3).

[[nip44_box3_58]]
 
These reasons must feel real and valid to the nurse at the time, but it is vital to remember that in the eyes of the law, failure to record information means that the care was not delivered.(1)
Nurses who do not achieve a high standard of record keeping practice are also inhibiting effective communication with the rest of their team and the safe and effective delivery of care to their patients/clients. This is especially the case when the record remains incomplete or unavailable because the nurse has not completed it at the time of the event. This practice occurs for many reasons, and is mainly due to the nurse's failure to prioritise the process of record keeping and documentation and allocate sufficient time to its completion. This is not to say that the nurses involved mean to put the client/patient or their colleagues at risk; rather they feel that other components of nursing care are more important and should be allocated a bigger portion of the finite time that is available (see Box 4).
All the strategies employed by the nurses in the scenarios in Box 4 may have enabled them to complete the records at some stage in the caring process. They may also provide the nurses involved with the illusion that they are saving time and are able to achieve more in the time that is available to them. However, they are not safe or acceptable practices because they rely heavily on memory.

[[nip44_box4_58]]
 
For example, a verbal handover is an incredibly useful process when seeking to provide continuity of nursing care, but it must be supplemented with written information if it is to be a safe and effective component of nursing care delivery. Furthermore the process of retaining the records in a space away from the patient/client and the rest of the team until the content is completed means that the nurse writing the record must remember the events of the contact at a later date. This is tremendously difficult to do with any degree of accuracy. More importantly this action means that both the record and the new information are not available to other members of the team and this places the patient/client at risk of missed or duplicated care, and the rest of the team at risk of providing incorrect nursing care.
The assumption that there is too much paperwork may also prevent nurses from achieving high standards of record keeping practice. One way that some nurses have sought to resolve this issue, which has come to light during the work of the NMC professional conduct committee, is that they have written the information in the record before the event takes place.(3) Again this presents its own set of problems, namely the confusion if the event does not actually take place or if the nurse writing the record fails to see the event through to its conclusion (see Box 5).

[[nip44_box5_59]]
 
Nurses undertaking record keeping and documentation in this way are placing the patient/client at risk. For example, what would happen in this situation if Tom were to be sick on the day of the immunisation clinic and unable to be there, or if one of the children was absent from school on the day of the clinic? This information is already written in the record and will remain in the record unless Tom remembers to correct the entry. Again this process relies heavily on memory and places the patient/client at risk because the entry states that s/he has been given an immunisation, which in fact they have not received.

Strategies for achieving a high standard of record keeping 
It is important to plan the process of recording information like any other process when delivering nursing care. Nurses must employ strategies that will help them to produce records that are succinct, legally sound, informative and contemporaneous (SLIC records). This can be achieved using the following simple three point plan:

Point 1. Stop and think
When planning the content of the record it is important to take a moment to think about the process. This will allow the nurse to systematically organise the information because it encourages him/her to think about the way in which they will record it. Often records are difficult to read because they include a lot of description and very little information about what this means in context. Therefore it is imperative that key pieces of information are recorded in a logical way from beginning to end and that an explanation is given that puts the information in context. Information without this meaning is of extremely limited use to anyone reading it.
There are many ways of organising information in this way and the final choice depends on personal preference. However, it is much more important to use the same process consistently over time because this will promote familiarity with the process and enable the nurse to record information in an effective and efficient way. Two particular methods have become familiar in the nursing field. These are referred to by the anagrams of RACIPAN and SOAPIER:(5)

RACIPAN

  • Reason for visiting.
  • Assessment.
  • Care plan.
  • Implementation.
  • Plan.
  • Actions.
  • New care plan.

SOAPIER

  • Subjective information (what the client says).
  • Objective information (what the practitioner observes).
  • Analysis.
  • Plan.
  • Implementation.
  • Evaluation.
  • Review.

Point 2. Get ready and prepare
Remember, lengthy descriptive accounts in records may allow you to feel that you have completed the record-keeping task, but they provide extremely little value in terms of information sharing. One way in which to improve this process is by recording information using problem statements. These encourage the nurse to record the information succinctly as s/he balances the information required so that the final record contains the pertinent points as well as enough information to explain what these mean (see Box 6).

[[nip44_box6_59]]
 
The example in Box 6 illustrates that separating the information, using the client's name and short sentences, is a useful strategy when writing problem statements because it makes the information easier and quicker to read. It is also helpful to include a sentence that sets the scene and puts the information into context, eg, Mrs Smith seen in clinic with baby Joe. From the example given in Box 6 it is possible to extract two clear problem statements from the first column, as illustrated in the second column.
It is also important to consider the way in which the information is to be presented in the record because this will influence the readability of the content. For example, the use of bullet points makes it easier to see the information at a glance. However, when using bullet points it is important not to leave spaces in the record that could be filled at another time by another person. This can be avoided by putting a line from the last word to the end of the page, which informs the reader that the information is complete despite not using all the space available.

Point 3. Get to the point
The final stage of the three-point plan is to get to the point. One way of doing this is to employ summarising techniques as this multifaceted process allows the writer to record information using clear, unambiguous language (see Box 7).(6)

[[nip44_box7_60]]

Again this avoids the use of lengthy prose and allows the writer to record information in an effective and efficient way. It also allows the writer to meet the requirements for a high-standard record (Box 8).

[[nip44_box8_60]]

Conclusion
There are many reasons for poor record keeping practices and they all seem to be valid at the time. However, it is important to remember that lack of time, staff shortages and heavy workloads are not valid reasons in a court of law, where the statement: "if it is not written down, it has not been done" is used.(1) In fact effective and efficient record keeping and documentation practices carry several fundamental messages which all nurses must remember. These include the fact that record keeping is not optional but an integral component of care provision. Effective and efficient record keeping and documentation promotes information sharing and thereby allows nurses to avoid allegations of misconduct and neglect, as well as avoiding duplicated or missed care delivery.
Finally record keeping and documentation is directly linked to the standard of professional practice, care delivery and the provision of coordinated care.
The strategies outlined in this article will enable you to meet the requirements for safe, effective and efficient record keeping and documentation in practice. However, as with all skill acquisition you must continually practise and update your record keeping and documentation skills through continuing professional development (CPD) in order to achieve the required standard of practice.(4)

References

  1. Nursing and Midwifery Council. Guidelines for records and record keeping. London: NMC; 2005.
  2. NMC. Fitness to practice annual report 2004-2005. London: NMC; 2005.
  3. NMC. Professional conduct committee and the conduct and competence committee (Audit 2005/06). London: NMC; 2007.
  4. Newland R. Record keeping and documentation: principles into practice. London: Unite/CPHVA; 2007.
  5. Luker K, Ore J. Health visiting. Towards community health nursing. London: Blackwell Scientific Publications; 1992.
  6. Thomson A. Critical reasoning: a practical introduction. 2nd ed. London: Routledge; 2002.

Your comments: (Terms and conditions apply)

"It is very easy to forget the basics of record keeping learnt as a student nurse. Very good article." - Pamela Boakye-Adjei