Nursing Documentation

Nursing documentation,record keeping andwritten communication

INTRODUCTION

Accurate record keeping and careful documentation is an essen-tial part of nursing practice. The Nursing and Midwifery Council(NMC 2002) state that ‘good record keeping helps to protect thewelfare of patients and clients’ – which of course is a fundamentalaim for nurses everywhere. You can look at the full Guidelinesfor records and record keeping by visiting the NMC website(www.nmc-uk.org).

It is equally important that you can also communicate by letterand e-mail with other health and social care professionals, toensure that they understand exactly what you mean.

NURSING DOCUMENTATION AND RECORD KEEPING

High quality record keeping will help you give skilled and safecare wherever you are working. Registered Nurses have a legaland professional duty of care (see Code of Professional Conduct,Ch. 1). According to the Nursing and Midwifery Council guide-lines (NMC 2002) your record keeping and documentation shoulddemonstrate:

— a full description of your assessment and the care planned andgiven

— relevant information about your patient or client at any giventime and what you did in response to their needs

— that you have understood and fulfilled your duty of care, thatyou have taken all reasonable steps to care for the patient or

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client and that any of your actions or things you failed to dohave not compromised their safety in any way

— ‘a record of any arrangement you have made for the continu-ing care of a patient or client’.

Investigations into complaints about care will look at and usethe patient/client documents and records as evidence, so highquality record keeping is essential. The hospital or care home, theNMC, a court of law or the Health Service Commissioner mayinvestigate the complaint, so it makes sense to get the recordsright. A court of law will tend to assume that if care has not beenrecorded then it has not been given.

Documentation

You will see lots of different charts, forms and documentation.Every hospital, care home and community nursing service willhave the same basic ones, but with small variations that work bestlocally. The common documents that you will use include someof the following.

Nursing assessment sheetThe nursing assessment sheet contains the patient’s biographicaldetails (e.g. name and age), the reason for admission, the nursingneeds and problems identified for the care plan, medication,allergies and medical history.

Nursing care planThe documents of the care plan will have space for:

— Patient/client needs and problems.— Sometimes, nursing diagnoses will be documented but these

are not used as frequently as in North America.— Planning to set care priorities and goals. Goal-setting should

follow the SMART system, i.e. the goal will be specific, meas-urable, achievable and realistic, and time-oriented. For exam-

PARKINSON AND BROOKER: EVERYDAY ENGLISH FOR INTERNATIONAL NURSES

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ple, a SMART goal would be that ‘Mr Lee will be able to drink1.5 L of fluid by 22.00 hours’. Some goals, such as reducinganxiety, are not easily measured and it is usual to ask patientsto describe how they feel about a problem that was causinganxiety.

— The care/nursing interventions needed to achieve the goals.— An evaluation of progress and the review date. This might

include evaluation notes, continuation sheets and dischargeplans. In some care areas you might record progress using aKardex system along with the care plan.

— Reassessing patient/client needs and changing the care plan asneeded.

Vital signsThe basic chart is used to record temperature, pulse, respirationand possibly blood pressure. Sometimes the patient’s blood pres-sure is recorded on a separate chart. Basic charts may also havespace to record urinalysis, weight, bowel action and the 24-hourtotals for fluid intake and output. More complex charts, such asneurological observation charts, are used for recording vital signsplus other specific observations, which include the GlasgowComa Scale score for level of consciousness, pupil size and reac-tion to light, and limb movement (Fig. 4.1).

Fluid balance chartThis is often called a ‘fluid intake and output chart’ or sometimesjust ‘fluid chart’. It is used to record all fluid intake and fluid out-put over a 24-hour period. The amounts may be totalled and thebalance calculated at 24.00 hours (midnight), or at 06.00 or08.00 hours. Sometimes the amounts are totalled twice in every24 hours (i.e. every 12 hours). Fluid intake includes oral, naso-gastric, via a gastrostomy feeding tube, and infusions given intra-venously, subcutaneously and rectally. Fluid output from urine,vomit, aspirate from a nasogastric tube, diarrhoea, fluid from astoma or wound drain are all recorded (Fig. 4.2).

NURSING DOCUMENTATION, RECORD KEEPING AND WRITTEN COMMUNICATION

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Fig. 4.2 Fluid balance chart. Reproduced with permission from Nicolet al, Essential Nursing Skills, Mosby, 2000.

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Medicine/drug chartIt is important for you to become familiar with the medicine/drug-related documents used in your area of practice. A basicmedication record will contain the patient’s biographical infor-mation, weight, history of allergies and previous adverse drugreactions. There will be separate areas on the chart for differenttypes of drug orders. These include:

— drugs to be given once only at a specified time, such as a seda-tive before an invasive procedure

— drugs to be given immediately as a single dose and only once,such as adrenalin (epinephrine) in an emergency

— drugs to be given when required, such as laxatives or anal-gesics (pain killers)

— drugs given regularly, such as a 7-day course of an antibioticor a drug taken for longer periods (e.g. a diuretic or a drug toprevent seizures).

All drugs, except a very few, are ordered using the BritishApproved Name, and the order (or prescription) will include thedose, route, frequency (with times), start date and sometimes afinish date. There is space for the signature of the nurse givingthe drug and, in some cases, the witness. It is vital to record whenyou give a drug. This is done at the time so that all staff knowthat it has been given, and do not repeat the dose. Likewise, ifyou cannot give the drug for some reason (e.g. patient is inanother department or their physical condition contraindicatesgiving the drug), make sure that this fact is recorded on the med-icine/drug chart and the doctor is informed if necessary.

Remember that in some situations you will need to record inthe nursing notes when you give patients a drug (e.g. if you giveanalgesic drugs (pain killers)).

Informed consentResponsibility for making sure that the person or the parents of achild have all the information needed for them to give informedwritten consent rests with the health practitioner (usually a doctor


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or nurse) who is undertaking the procedure or operation. Thisinformation will include:

— information about the procedure/operation— the benefits and likely results— the risks of the procedure/operation— the other treatments that could be used instead— that the patient/parent can consult another health practitioner— that the patient/parent can change their mind.

Young people can sign the consent form once they reach theage of 16 years and/or have the mental capacity to understandfully all that is involved. If the young person cannot sign the form,the parent or legal guardian may sign it. If an adult lacks the men-tal capacity, either temporarily or permanently, to give or denyconsent, no person has the right to give approval for a course ofaction. However, treatment may be given if it is considered to bein the person’s best interests, as long as an explicit (clear) refusalto such action has not been made by the person in advance.

Doctors do most invasive procedures and operations, but nurs-es in the UK are extending their practice to include many proce-dures that were previously done by doctors. You may work withnurses who do procedures such as endoscopic examinations, soit is becoming more common for nurses to obtain informed con-sent. The patient or parent and the healthcare practitioner bothsign the consent form.

When your patients are due to have any invasive procedure,always check their level of understanding before it is scheduledto happen. If you are not sure about answering a question, askthe healthcare practitioner who is doing the procedure to see thepatient and explain again. It is essential that the consent form issigned before the patient is given a sedative or other premedica-tion drugs.

Incident/accident formAny non-routine incident or accident involving a patient/client,relative, visitor or member of staff must be recorded by the nurse


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who witnesses (sees) the incident or finds the patient/client afterthe incident happened. Incidents include falls, drug errors, a vis-itor fainting or a patient attacking a member of staff in any way.

An incident/accident form should be completed as soon aspossible after the event. Careful documentation of incidents isimportant for clinical governance (continuous quality improve-ment, learning from mistakes and managing risk, etc.) and in caseof a complaint or legal action (see above).

The following points provide you with some guidance:

— be concise, accurate and objective— record what you saw and describe the care you gave, who else

was involved and the person’s condition— do not try to guess or explain what happened (e.g. you should

record that side rails were not in place, but you should notwrite that this was the reason the patient fell out of bed)

— record the actions taken by other nurses and doctors at the time— do not blame individuals in the report— always record the full facts.

Guidelines for documentation and record keeping

The basic guidelines for good practice in documentation andrecord keeping apply equally to written records and to computer-held records.

The Nursing and Midwifery Council (NMC 2002) has said thatpatient and client records should:

— be based on fact, correct and consistent— be written as soon as possible after an event has happened to

provide current (up to date) information about the care andcondition of the patient or client

— ‘be written clearly and in such a way that the text cannot beerased’ (rubbed out or obliterated)

— be written in such a way that any alterations or additions aredated, timed and signed, so that the original entry is still clear

— ‘be accurately dated, timed and signed, with the signature


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printed alongside the first entry’ (this is even more importantbecause your last name may not be very common in the UK)

— ‘not include abbreviations, jargon, meaningless phrases, irrele-vant speculation and offensive subjective statements’

— ‘be readable on any photocopies’.

Note: Although the NMC guidelines clearly state that abbrevia-tions should not be used in patient/client records, because youwill see and hear abbreviations used in medical notes and han-dover reports, a list of commonly used ones is provided inChapter 9 to help you understand what people mean.

The NMC goes on to say that records should:

— ‘be written, wherever possible, with the involvement of thepatient, client or their carer’

— ‘be written in terms that the patient or client can understand’— ‘be consecutive’ (uninterrupted)— ‘identify problems that have arisen and the action taken to rec-

tify’ (correct or put right) them— ‘provide clear evidence of the care planned, the decisions

made, the care delivered and the information shared’.

OTHER WRITTEN COMMUNICATION

Letter writing

Letters may be professional, business or private. The private typeis obviously easier to write, but there are, nevertheless, certainbasic rules to be remembered.

The envelope— It is becoming increasingly common in the UK to put the

sender’s name and address on the back of the envelope, par-ticularly when sending packages and important documents.However, most people in the UK throw away envelopes assoon as letters are opened, so if you want an answer you mustwrite your full address on the letter itself.

— It is correct to address people as Mr, Ms, Mrs or Miss with ini-


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tials and last name (e.g. Miss J Smith or Mr O Massoud). Manywomen prefer to be addressed as Ms, regardless of marital sta-tus, and certainly Ms should be used where you are unsure. Amarried woman or a widow may be addressed as Mrs unlessshe has some other title or is known to prefer Ms. An unmar-ried woman may be addressed as Miss. There is a growing ten-dency to omit the title completely and simply use the name(Jill Smith or Omar Massoud) on the envelope. Other titles,such as Professor or Dr, should be used if appropriate.

— When writing a professional or business letter to a college, acompany, an hotel, a professional journal, etc., the letter mustbe addressed to someone. You would, in fact, write to thePrincipal of a college, to the Secretary or Manager of a com-pany, to the Manager or Receptionist of an hotel and to theEditor of a professional journal.

— The address follows the name, in this order:i. the number of the house and the name of the street (on

the same line), or the name of the house (e.g. AllgoodsCottage) with the street name on a separate line

ii. village, town or cityiii. county (and country if written from abroad)iv. postal code.

For example:

Ms C Gower116 Tenby DriveFakenhamNorfolkPE57 1ZZ

As can be seen from the above example, usual practice is to omitpunctuation from the details of the name and address. On word-processed or typewritten letters, indentation is no longer used.

The letter— The sender’s address is written in full at the top right-hand side

of the paper. It is not usual to put your name there. In care


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homes and hospitals and other places where official writingpaper is printed, the address, including the telephone num-ber and e-mail address, is either on the right-hand side or inthe centre.

— In private letters the date is usually written below the sender’saddress in the order: day, month, year (e.g. 7 June 2006, orsometimes as 7.6.2006).

— In a professional or business letter, the name and address ofthe person to whom the letter is written are placed on the left-hand side, at the top, with the date written below the address.

— When you write to an unknown person the letter begins ‘DearSir’, or ‘Dear Madam’ if it is to a woman. If you are unsure,write ‘Dear Sir/Madam’.

— When you have met the person or corresponded before, thelast name is used and the letter begins with ‘Dear Dr Sanchez’.If you know the person well or they have signed previous let-ters to you with their first name it is usual to address them bytheir first name (e.g. ‘Dear Rao’).

— When writing to a friend, one begins ‘Dear John’, ‘Dear Farida’,or ‘My dear Elizabeth’, to a closer friend.

— If the letter begins ‘Dear Sir or Madam’, the ending should be‘Yours faithfully’.

— If the letter begins, ‘Dear Ms Steele’ or some other name in aprofessional or business correspondence, the ending shouldbe ‘Yours sincerely’.

— ‘With best wishes’, ‘With kindest regards’ or ‘Yours’ are quiteusual endings for letters to friends, or colleagues who youknow well.

— Phrases such as ‘Yours respectfully’ are no longer used. Nor isit UK practice to use very flowery, effusive (over the top) lan-guage in a professional or business letter. Write clearly andsimply and briefly in a professional or business letter.

— Each new subject or aspect of the subject should be dealt within a separate paragraph. In a handwritten letter the para-graphs are marked by starting a little distance from the leftside, or in word-processed letters by leaving space between


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the paragraphs.— It is important to print your name in block letters underneath

your signature, as names are often very difficult to read inhandwriting. Also, note that in the UK the numbers one andseven are written thus: 1, 7. Figures written in the style usedin continental European countries may cause delay, and evenloss, to correspondence

— In situations where you have written asking for informationsuch as details of a course, the institution may write to thankyou for your interest and ask you to send an envelope withyour address and enough postage stamps (stamped addressedenvelope), so they can send you the printed material. Therequest for such an envelope is usually abbreviated to ‘pleasesend/enclose an SAE’.

Writing electronic mail

The use of electronic mail (e-mail) is increasingly important forboth professional and private communication. The following listprovides you with some guidance:

— Remember that e-mail cannot be 100% secure or confiden-tial – it may be read by other people. It is especially importantto make sure that e-mail containing patient/client details isonly seen by those authorised to do so. Always follow thelocal protocols for keeping computer records confidential.

— It is important to be concise. People often get many e-mailseach day and you want them to read yours.

— It is good sense to think before you send any written commu-nication – you can change your mind right up to putting a let-ter in the postbox, but once you click on post/send for e-mailit is too late to change your mind. Feeling upset or angry is notan ideal time to send an e-mail.

— In common with professional or business letters, it is usual toaddress people as Mr, Ms, Mrs, Miss, Dr, etc., unless you knowthem well and generally use their first name.


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— It is not appropriate to use e-mail abbreviations (e.g. ‘BTW’ for‘by the way’) or nursing/medical abbreviations in professionale-mail. Not everyone will know what the abbreviation means,or an abbreviation may have more than one meaning.

— It is not necessary to overuse punctuation in e-mail, such asusing many exclamation marks. It is much better to let yourtext emphasise the important points. Likewise, it is not usualto use upper case (capital) letters for whole words, as this isthe e-mail equivalent to shouting.

— A reply is not always instant. It is important to remember thatalthough e-mail usually reaches its destination in just a fewminutes, it can take longer. Some people read and reply totheir e-mail several times a day, but others may only checkonce a week.

REFERENCES

Nursing and Midwifery Council (NMC) 2002 Guidelines forrecords and record keeping. NMC, London.

FURTHER READING

Hoban V 2003 How to ... handle a handover. Nursing Times99(9):54–55.


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Nursing Documentation

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Transcript of Nursing Documentation