Record keeping

Written communication is as important in the health care arena as both verbal and non-verbal communication. Maintaining clear, concise but comprehensive client care records is absolutely essential both in terms of providing continuity of client care of a high standard and in terms of meeting legislative requirements.

Remember, in a court of law it is assumed that if the care was not documented then it didn’t happen.

With the advent of information technology, computerized information systems are being increasingly used to record, store and evaluate information pertaining to clients. These are proving very useful in terms of easier and speedier access to information both within and across care environments, for example department to department, hospital and community. Whatever method is used in your area, however, it is important that you familiarize yourself with the systems and ensure that you do not breach client confidentiality.

The Nursing and Midwifery Council has adopted the standards for record keeping produced by their predecessors, the UKCC (1999). The main tenets are summarized below.
Client records should:

• be factual, consistent and accurate
• be written as soon after the event as possible and, if possible, with the involvement of the client
• be clear, legible and readable following photocopying
• be written in a manner that cannot be erased
• be timed, dated and signed with name printed by the side and indicating your role, for example PA Hilton (PA Hilton, Staff Nurse)
• be devoid of abbreviations, jargon or meaningless phrases such as ‘Bed bath given’
• not contain any subjective, offensive statements or irrelevant speculation
• be written in a language understandable by the client
• identify client problems and steps taken to rectify them
• provide evidence of the care that has been planned and delivered
• include information that has been shared with others
• include evidence of evaluation of the efficacy of care delivery.