UNIT 11DOCUMENTATION

ANISA FATMALA :1414401D004

AULIA AZIZAH: 1414401D006

FITRIA NURJANNAH: 1414401D014

CHAPTER 11• LEARNING OUTCOMES

By the end of this chapter you will have an understanding of the best practice in nursing documentation, record keeping and written communication. Effective record-keeping is essential to facilitate robust communication between healthcare professionals.

• NURSING AND MIDWIFERY COUNCIL

The Nursing and Midwifery Council (or NMC) is the UK regulator that safeguards the health and wellbeing of the public, and strives towards the consistent delivery of high-quality health care. The NMC’s vision, mission and values also include nursing and midwifery students.

The NMC (2009) has also issued guidance for the principles of good record-keeping, stating that:

1 . Handwriting should be legible.2. All entries to records should be signed. In the case of

written records, the person’s name and job title should be printed alongside the fi rst entry.

3 .In line with local policy, you should put the date and time on all records. This should be in real time and chronological order and be as close to the actual time as possible.

4. Your records should be accurate and recorded insuch a way that the meaning is clear.5. Records should be factual and not include

4. Your records should be accurate and recorded in such a way that the meaning is clear.

5. Records should be factual and not include unnecessary abbreviations, jargon,meaningless phrases or irrelevant speculation.

6. You should use your professional judgement to decide what is relevant and what should be recorded.

7. You should record details of any assessments and

reviews undertaken and provide clear evidence of the arrangements you have made for future and ongoing care. This should also include details of information given about care and treatment.

8. Records should identify any risks or problems that have arisen and show the action taken to deal with them.

9. You have a duty to communicate fully and effectively with your colleagues, ensuring that they have all the information they need about the people in your care.

10 .You must not alter or destroy any records without being authorised to do so.

11 .In the unlikely event that you need to alter your ownor another healthcare professional’s records, youmust give your name and job title, and sign and date the original documentation. You should make sure that the alterations you make, and the original record, are clear and auditable.

12. Where appropriate, the person in your care, or their carer, should be involved in the record-keeping process.

13. The language that you use should be easily understood by the people in your care. Records should be readable when photocopied orscanned.

15 You should not use coded expressions of sarcasm or humorous abbreviations to describe the people in your care.

16 You should not falsify records.

• LEGAL ISSUESClinical records are part of the ongoing process

of providing the correct patient care, but are frequently seen by nurses as a means of providing evidence for use in litigation cases, and are written in this style.

• ROOT CAUSE ANALYSISWhen mistakes occur in the clinical setting, the

clinical nrecords are viewed as part of the investigation. This investigation is referred to as a root cause analysis whereby the incident is investigated in full, looking at what happened and when, what actions were taken and why they were taken.

• ACCOUNTABILITY

According to the NMC (2008), registered nurses areaccountable to:

• the NMC to demonstrate fi tness to practice and adherence to the code of conduct;

• their employer or trust to demonstrate fulfi lment of their contractual agreement and that

they are performing at the right standard for their role; • the courts if there are claims of negligence or criminalacts

(law);• the patient and family.

• NURSING DOCUMENTATIONWithin the healthcare profession, whether you

work in a hospital, care home or community setting, you will see many different charts, forms and types of documentation.