SampleRecord Keeping

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Contents

Index. Page 2Learning outcomes. Page 3Links to Care Quality Commission (CQC) outcomes. Page 3Introduction. Page 4

Unit One. Pages 5 - 6Definitions of health records and documentation and types of health record.Unit One Questions. Page 7

Unit Two. Pages 8 - 10The purpose and functions of health records and documentation.Unit Two Questions. Pages 11 - 12

Unit Three. Pages 13 - 15Effects of good and poor health record keeping.Unit Three Questions. Pages 16 - 18

Unit Four. Pages 19 - 22Legal and professional issues in health record keeping.Unit Four Questions. Pages 23

Unit Five. Pages 24 - 27Style and content.Unit Five Questions. Page 28

References and further reading. Page 29

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Learning outcomes.

• Definewhatismeantbyrecordsanddocumentation.• Identifythepurposeandfunctionofrecordsanddocumentation.• Understandtheeffectsofgoodandbadrecordkeeping.• Identifythelegislationinvolvedinrecordkeeping.• Understandtheprinciplesofgoodrecordkeeping.

Links to Care Quality Commission (CQC) outcomes.

Outcome21:Records.

N.B:Weareawarethatofficialpracticeistousetheterms“serviceusers”or“peopleusingthisservice”todescribethosereceivingcare.Weprefertheterm“client”anduseitthroughoutourtrainingpackage.

Key:

worksheet important

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Introduction.

Intoday’severchanginghealthcareenvironment,accuratehealthrecordsanddocumentationremainabsolutelyessential.In2010theFrancisInquiry,ahighprofileinvestigationintostandardsofhealthcareinaNHSTrust,statedthatthewritingofaccuraterecordshasaprofoundeffectontheoverallwelfareoftheclientastheypromotehighstandardsofclinicalcareandallowforeffectivecommunicationbetweentheclient,familyandallmembersofthecareteam.

Taylor (2003) states that documentation and record keeping remains the primary source of communication for all health care professionals.

Aspartofitsinspectionregime,theCareQualityCommission(CQC)monitorsthestandardsofhealthrecordsanddocumentationinestablishmentssuchasnursingandresidentialcarehomes.Althoughthereisnoonemethodofhealthrecordkeeping,therearerecognisedprinciplesandstandardsthatcanbeusedbyallhealthprofessionalsasaframeworkinmaintainingaccuratecarerecords.

Accurate record keeping is regarded as a carer’s `duty of care’; an important skill which needs to be performed with due diligence and in accordance with best practice guidelines and local policy.

Aim.

Theaimof thismanual is toprovideanawarenessof theprinciplesofmaintainingaccuraterecordkeepinganddocumentation.

Writteninaccordancewithcurrentbestpracticeguidelinesandrelatedliterature,itissuitableforallcareworkerstoupdateanddeveloptheirknowledgeandskillsinrecordkeeping.

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Unit One

Definitions of health records and documentation and types of health record.

Initially,weneedtoconsiderwhatismeantbytheterms‘healthrecord’and‘documentation’.Thenwewilllookatthedifferenttypesofhealthrecordanddocumentationthatyouuseinyourownworkenvironment.

The Collins English dictionary defines documentation as `documents supplied as proof or evidence of something’.The dictionary also defines records as `a document or other thing that preserves information’

An important piece of law which governs the need of accurate health records is the DataProtectionAct(1998).

The Data Protection Act (1998), section 68(1) (a) defines a health record as`any electronic or paper information recorded about a person for the purpose of managing their health’, these records will include medical and patient records, case notes, mental health notes and obstetric records.

TheDataProtectionAct(1998)statesthatahealthrecordisanyrecordwhich:

• Consistsofinformationrelatingtothephysicalormentalhealthorconditionofanindividual,and

• Hasbeenmadebyoronbehalfofahealthprofessionalinconnectionwiththecareofthatindividual.

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Different types of health records.

Althoughtheuseofelectronicrecordsisincreasing,andhealthrecordsanddocumentationcancomeinavarietyofdifferentformats,theuseofpaperbasedhealthrecordsremainscommonplace.

TheNursingandMidwiferyCouncil (NMC2010)state that theprinciplesofaccurate recordkeepingapplytoalltypesofrecords,regardlessofhowtheyareheld,thesecaninclude:

Broadly speaking health records can come under three main headings:

• Nursing records – admission forms, daily care plans, food and fluid charts, baselineobservationcharts,weightcharts,advancecareplanningdocuments,woundcharts.

• Medical/doctors’records–pathology/laboratoryreports,bloodresults,clientcasenotes,operationnotes,prescriptions,x-rayreports.

• Multidisciplinary records – social care reviews, speech and language therapy (SALT)assessments,dieticianreviews,occupationalhealthreports,eyecheckrecords.

Typesofhealthrecord

&Documentation

Emails

Letterstoandfromotherhealthprofessionals

Laboratoryreports

X-rays

Referralforms

Incidentsreportsandstatements

PhotographsVideos

Textmessages

Charts,e.g.woundcarecharts

Printoutsfrommonitoring

equipment,e.g.ECG(heartmonitoring)

Handwrittenclinicalnotes

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Unit One Questions

Whichbodymonitorsthestandardandqualityofhealthrecordsincarehomes?2.

Taylor(2003)statesthathealthrecordsanddocumentationaretheprimarysourceofwhatforallhealthcareprofessionals?

1.

HowdoestheCollinsEnglishdictionarydefinearecord?3.

Give threeexamplesofahealth recordordocumentationyoumightsee relating toeachheading.Nursingrecords:

5.

1.

2.

3.

Multidisciplinaryrecords:1.

2.

3.

Medical/doctors’records:1.

2.

3.

Canyoulistthreedifferentwaysofrecordinginformation?4.

1.

2.

3.

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Unit Two

The purpose and functions of health records and documentation.

Duetothevarietyofhealthrecordsandthedifferenttypesofinformationheld,itisunderstandablewhythekeepingofaccuraterecordsiscruciallyimportantinmaintainingtheoverallcontinuityoftheclient’streatmentandcare.Italsoprotectstheclient’shealthandsafetybypreventingpotentialmistakesintreatment(Owen2005).

In2010theNursingandMidwiferyCouncil(thestatutorybodyforregisteringandregulatingtheprofessionalconductofnursesandmidwives)producedguidanceonrecordkeeping.

`Good record keeping is an integral part of nursing and midwifery practice, and is es-sential to the provision of safe & effective care. It is not an optional extra to be fitted in if circumstances allow’ (NMC 2010).

Following thisstatement itwouldbebeneficial to identifyotherpurposesand functions thathealthrecordshaveintheoverallcareoftheclient.

Griffith&Tengnah(2008)suggestthataccuratehealthrecordsallowaclient‘sprogresstobemonitoredandaclinicalhistorytobedevelopedsocareprovisionscanbeplannedandputintoplacetomeettheneedsoftheclient.

Healthrecordsalsoallowforthecontinuingevaluationofcareprovidedandidentifywhetheralternativesarenecessaryinordertomeettheneedsoftheclient.Anexampleofwhichisinthescenariobelow.

MrTeddyCollins,84,isaclientofaresidentialhome.Heiscomplainingofjointpaininhisrightknee,itisworseatnightandhissleeppatternisfrequentlydisturbedduetothepain.HisGPhaspreviouslyprescribedhimtwoparacetamoltabletstobetakenfourtimesaday.

FollowingadiscussionwithMrCollins,anassessmentofhis levelofpainwasperformedusingapainassessmentchart.Fromthisandotherinformationgatheredfromhisnursingrecordsandcurrentmedicationadministrationsheets,itwasconcludedthathispainwasnotbeingcontrolledbytheparacetamol.

Thereforeanurgentre-evaluationofhispainreliefwasrequestedfromhisownGP.

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Recordsalsohaveaveryimportantlegalfunction.Classifiedaslegaldocumentsallandanyhealthdocumentationcanbecalledupontobeusedasevidenceinthefollowingsituations;

1. Courts of law, civil and criminal.2. Coroners’ courts.3. Tribunals.4. Investigations surrounding complaints of care provision.5. Internal employment disciplinary cases.6. Fitness to practice cases of an individual health professional.

In its factsheet(HealthRecords:Overview)www.nhs.uk theNHSEnglandstate thathealthrecordsplayanimportantroleinmodernhealthcareandcurrentlytheyhavetwomainoverallfunctions:

Primary function.

Theprimaryfunctionofhealthcarerecordsistorecordimportantclinicalinformation,whichmayneedtobeaccessedbyhealthprofessionalsinvolvedinthecareoftheclient.Theinformationcontainedinhealthrecordsincludes:

• Thetreatmentsclientshavereceived.• Anyallergiestheclienthas.• Istheclienttakinganymedication.• Hastheclientanyadversereactionstoanymedications.• Hastheclientanychronic(longlasting)healthconditionssuchasdiabetesorasthma.• Theresultsofanyhealthtestssuchasbloodtestsorx-rays.• Anylifestyleinformationthatmayberelevant,suchaswhethertheclientsmokes.• Personalinformation,suchasage,employment,address.

Secondary function.

ThesecondaryfunctionofhealthrecordsistoimprovepublichealthandtheservicesprovidedbytheNHS,suchastreatmentsforcancerordiabetes.Healthrecordscanbeused:

• Todeterminehowwellaparticularhospitalorspecialistunitisperforming.• Totrackthespreadof,orriskfactorsfor,aparticulardisease,e.g.winterflu.• Inclinicalresearch,todeterminewhethercertaintreatmentsaremoreeffectivethan

others.

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Accuratehealthrecordsanddocumentationarefundamentalinprovidingacomprehensiveandaccurateaccountofcaregiven.Theysupportthecontinuityofclientcentredcareandensureclearaccountabilityastheyshowexactlywhodidwhat.

Documentation is essential to show what decisions weremade and why and this may benecessarytodemonstratecompliancewithlegislation,forexamplethe‘bestinterest’principlesoftheMentalCapacityAct.

Good records provide away of detecting problems and care alternatives and are effectivechannelsofcommunicationbetweentheclient,familyandcarers.

Purpose / function of health records.

• Assessment, planning, intervention and evaluation of care - admission form, daily careplanningsheets.

• Communicationbetweenhealthprofessionals–staffhandoversheets,doctor’swardrounds.• Physiologicalfunctions&activitiesofliving-observationcharts,e.g.bloodpressure,pulse,

temperature,fluidanddietcharts.• To record health and safety issues - accident books, risk assessments, critical incident

sheets.• Toprovideevidenceofdailycare-dailyrecordsheets,careplans.• Detailsofclients’choices,consentanddecisionsforcare-advancecareplanning,living

wills,treatmentoptions,DNARdecisions,useofrestraintbelts,useofbedrails.• Supportingevidencefordecisionsandinterventionsmadebyhealthprofessionals-wound

carecharts,socialservicesreviewsnotes,reviewsbySALTteam.• Detailsoffamilyinputorconcerns-socialservicescarereviews,nursingnotes.

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Unit Two Questions

What is the Nursing and Midwifery Council’s (NMC) current statement on recordkeeping?

1.

Whichhealthrecordsordocumentationcanberegardedaslegaldocuments?2.

Listthreesituationswherebyhealthrecordsanddocumentationcanbeusedaslegalevidence?

3.

1.

2.

3.

Theprimaryfunctionofhealthrecordsistorecordimportantclinicalinformation.Give3examplesofwhatthisinformationshouldbe.

4.

1.

2.

3.

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1.

Identify3purposesorfunctionsofhealthrecordsandgiveanexampleofeach.5.

2.

3.