Top tips from Tanis - Principle E

Published: 20 September 2012

In each of our e-newsletters we are focusing on each of the Principles of Nursing Practice, as they are such a fundamental part of good nursing care. Whether you are a health care assistant (HCA) or an assistant practitioner (AP), and whether you work in acute care, mental health, the independent sector or indeed anywhere, the principles will apply to you and your colleagues.

The principles make clear exactly what quality nursing care looks like. They were developed with patients and for patients. They can be used by nursing staff to reflect on their own practice and evaluate nursing care. They can also be shared with patients and their families or carers so they can give feedback on the care provided.

Read about the Principles of Nursing Practice.

In this e-newsletter we take a look at Principle E:

Nurses and nursing staff are at the heart of the communication process: they assess, record and report on treatment and care, handle information sensitively and confidentially, deal with complaints effectively, and are conscientious in reporting the things they are concerned about.

This principle covers one of the most important and fundamental aspects of nursing care, and it is clear that communication is much more than simply verbal and non-verbal methods of relating to each other and our patients or clients.

This principle outlines our documentation processes, which can cover a huge range of methods of recording care given. It covers confidentiality issues, complaints management and also raising concerns. But today I would like to focus on record keeping, as this will affect everyone working in health care.

There are some very straightforward principles relating to record keeping. Some of these are noted below.

• All records must be signed, timed and dated if handwritten. If computer held they must be traceable to the person who provided the care that is being documented.
  Make sure that you always use your own user name and password. Never share this with anyone or use someone else’s log in to record care that you have given.

• Records must be clear and accurate, and provide information about the care given and arrangements for future and ongoing care.
  Your records must be relevant and sufficiently detailed so that people who read them understand what has happened and what is planned

• Jargon and speculation should be avoided.
  We all get used to using certain expressions within our workplace that may not mean anything to someone working outside of that setting. Likewise, abbreviations should not be used unless they are universally recognised. For example, SOB may mean “short of breath” in one setting, and “stood out of bed” in another, so should not be used as this could cause confusion.

• When possible the person in your care should be involved in the record keeping and should be able to understand the language used.
  It is good practice to explain what you are going to document so that all parties understand what is happening and what will happen. Remember that the people in your care may request to see their notes – there are processes for this so check always out your local policies if you are asked.

• Records should be readable when photocopied or scanned.
  This is simple common sense advice so do not use pencil or a light coloured pen in hand written notes. Many organisations require staff to use black ink for all records.

• In the rare case of needing to alter a record the original entry must remain visible (draw a single line through the record) and the new entry must be signed, timed and dated.
  Do not use erasing fluid as it is essential that the original record can be seen.

• Records must not be destroyed unless you have been authorised to do so.
  This is self-explanatory. There are legal guidelines on how long records must be kept, and they vary according to the circumstances.

Q. The registered nurses where I work always countersign my notes, even if they haven’t seen the care that I have given. Is this necessary?

A. Record keeping can be delegated to HCAs, APs and nursing student so they can document their care. As with any delegated activity, the registered nurse needs to ensure that the student, HCA or AP is competent to undertake the task and that it is in the patient’s best interests for record keeping to be delegated.

Supervision and a countersignature are required until the student, HCA or AP is deemed competent at keeping records. Registered nurses should only countersign if they have witnessed the activity or can validate that it took place. However, it is also important to take local policy into account so make sure that you check this out.

The RCN has just produced a new resource which summarises these points. It can be ordered from RCN publications using the publication code 004 294 or downloaded from the RCN website.

Read a useful article on Principle E

Read the NMC Record Keeping guidance for nurses and midwives