Standards of record keeping
Despite the increased availability and use of technology in healthcare, the majority of patient records are still hand written. Hand written records such as care plans and observation charts may present a number of challenges in relation to their purpose as tools to record patient care and their use as a permanent record of patient care. These records may be the most convenient for the professional to use but present many issues in relation to understanding and communication.
Poor standards of hand written notes combined with the use of abbreviations can be misunderstood and lead to errors in the standard of care being delivered to the patient. The NMC (2009) set out clear principles for making, storing or disposing of a patient health care record especially in relation to hand written notes. They state that all hand written records should be legible. All entries should be signed by the practitioner dated and timed with the individuals' signature and job title printed alongside the first entry. To ensure all records are auditable, most Health Board, human resource departments now require that all practitioners contributing to patient records to provide in full their job title with a sample of their signature.
Advanced practitioners regularly contribute to patient care autonomously and record the care provided within patient records and are expected to ensure their signature is legible and recorded formally. Any patient records should be factual, consistent, accurate and written so that the meaning is clear. They should be written as soon as possible after an event, in non-erasable ink that will be readable when photocopied or scanned.
All patient records should also provide clear evidence of, care planned, decisions made, care delivered and other related information. It is also recommended that any record should identify problems that have arisen in relation to the patient together with any actions taken. In relation to the content, style and adequacy of any patient health record the NMC (2009) also suggest that they should not include:
- abbreviations
- jargon
- meaningless phrases
- irrelevant speculation
- offensive subjective statements
As senior professionals, most advanced practitioners will be very familiar with the need to accurately describe the patient and the care delivered to them without using meaningless phrases, irrelevant speculation or offensive subjective statements. However on occasions they may be tempted to speculate on the source of their patients' condition, for example describing a patient as drunk without providing evidence of their alcohol level. If excerpts from a patients' record were to be requested by the patient in the course of an enquiry or complaint, the use of such speculative and judgemental descriptions may be challenged.
Practitioners in high acuity settings may be tempted to use commonly used medical terms, colloquiums and abbreviations as a form of shorthand, without considering the potential for these to be misunderstood should these records be read by a member of a different team. For example common abbreviations used in one speciality may mean something completely different in another speciality e.g.
PID - prolapsed intravertebral disc/pelvic inflammatory disease
or
TOF - tetralogy of Fallot/tracheo-oesophageal fistula
Use of abbreviations can lead to considerable confusion and perhaps the wrong conclusion being reached on the patient's condition and care interventions. To help avoid this confusion and assist in development of speedy and accurate patient documentation by members of the healthcare team, many health boards have now developed their own glossary of acceptable abbreviations, publishing them within the local documentation policy with a full explanation of the terms. This allows the healthcare team to use these abbreviations within patient records and prevent misunderstandings by colleagues in other departments.
