Recordkeeping Guide PDF

Recordkeeping Richard Griffith  Communicate clearly Vital any directions you give or receive are understood Ensure patients understand your instructions and advice Avoid abbreviations Write clearly enough for a busy or careless person to be able to read it What is this for What d...

Recordkeeping Richard Griffith  Communicate clearly Vital any directions you give or receive are understood Ensure patients understand your instructions and advice Avoid abbreviations Write clearly enough for a busy or careless person to be able to read it What is this for What does this mean? Pat male 73 PH DM II, AH, IC att 4 pain in tx  Good record keeping is an integral part of professional practice Essential to the provision of safe and effective care. Recordke Not an optional extra to be fitted in if circumstances allow. eping Professional Codes policy National standards Statutory regulations Must be met to ensure good clinical record keeping practice. NMC - Keep clear and accurate records relevant to your practice Clinical Records provide evidence of your function involvement with a underlies patient. They need to be a very sufficiently detailed therefore to demonstrate important this involvement. Have you discharged legal your duty of care purpose.  Record keeping crucial First EITHER Justify contact SUPPORT Never your for YOU OR neutral actions investigat CONDEMN ion YOU  1. Be accurate, factual and must not include jargon, meaningless phrases or text style abbreviated language. 2. Identify the date and time in 24 hour format. Be in real time and chronological order, and be as close to the actual time of the event as possible. 3. Demonstrate details of all assessments, risk Entries in assessments, plans of care and reviews undertaken, and provide clear evidence of the arrangements records made throughout a person’s journey from admission to discharge from the service. must 4. Identify dates and times for the evaluation of the plan of care. 5. Demonstrate that review of the plan of care has been carried out. 6. Demonstrate evaluation of care and treatment. 7. Demonstrate that discharge planning, where appropriate, has commenced at the time a person enters a care setting.  All entries to patient records are legible, accurate and attributable. 1. Written entries must be made in black ink and in legible handwriting. 2. Must be signed or contain a unique identifier in the case of electronic records. In the case of written records, the person’s name and job title must be Presentati printed alongside the first entry, for example, on a document signature recognition register. on 3. Made in error must be identified with a single line strike through, and the name, job title, signature of the HCP making the record, with the date and time of strikethrough, recorded in the original document. 4. Made as an alteration or addition should be identified by the name, job title, and signature of the nurse/midwife recording the alteration or addition, and the date and time of alteration/addition. 5. Must be made in records with a clearly identified unique patient number on each separate element.  1. Must demonstrate the involvement of the person for whom care is being provided or where appropriate, and with the person’s consent, the involvement of his/her carer, in the record keeping process. 2. Must demonstrate that the needs and Professional/ preferences of the person for whom care is patient being provided, where appropriate, have been included in the record keeping partnership process. 3. Must demonstrate that appropriate consent for care/treatment has been sought from the patient/client. 4. Must be written in a way which can be easily understood by the person for whom care is being provided.  Record is truthful and based F – factual on fact Five A – accurate What is recorded is clear, unambiguous, dated, timed and signed principles of good C – consistent The record is reliable and dependable record keeping The record has been T – timely contemporaneously written The record is communicated S – shared to the care team, patient and carers F - factual Record is based on facts Matters described factually as a result of your own observation Your opinion or interpretation of behaviour or events which you observed Matters recorded on file or told to you by others which are relevant but which you cannot verify Justifying your conclusions. have you demonstrated the factual basis for each part of your conclusion  Consider the statements in the worksheet are they facts or supposition? There are inadequate play and stimulation opportunities available The bruise and swelling are consistent with Fact or hitting his head on the door This is the first incident of abuse to the suppositio vulnerable man The flat is unsuitable for a person with Huntingdon’s disease n? Mrs Green is good at keeping her flat tidy The child said his dad hit him I saw Peter playing with his toys when I last visited Mrs Green does not display appropriate caring skills when relating to her mother Man transferre Ombudsman No evidence that man had been d to properly assessed as being safe to different travel unescorted. Record keeping in general was hospital in substandard, with documentation taxi poorly completed by staff, if at all. Ward Sister had falsified an entry without in the records more than a year escort after he had died.  What is recorded is clearly written free from error in content or spelling A- dated, accurate timed and signed Take home medicine information 17 Care decisions Your record should include Often on a multi disciplinary the background to the or interagency basis. discussion and its outcome. Indicate the reason for the Corroborate any other legal decision and corroborate the requirement or form account of other team completed by the patient in members. your presence. Details of telephone calls made, even if unanswered, to the patient or to others about Telephone Calls to other the patient and discussions agencies must be followed up arising from them with date in writing and time should be included as should referrals to specialist practitioners.  Records must be written in a way that identifies the patient for throughout the Patient document. Name Identificati Record number on Address or or addressograph label On every page of the record. Indelible Writing with indelible ink or typeface is essential for two reasons. Record must stand the test of time. It may be many years before they are referred to again and a faded record is of little value as evidence. Credibility of your record as evidence is enhanced by its being made at the time of the incident. Indelible ink or typeface reassures the court that the entry has not been subsequently altered in any way.  Record must demonstrate the continuity of care is person-centred and that the Communicat person’s family/carer are ing with supported and included in People and decisions about care and their Essential treatmentthat the views and Families comments of the person, or his/her family, regarding any aspect of care and treatment are included using quotation marks Records ESSENTIAL ALL RECORDS, RECORDS ARE THE KEY must be INSTRUCTIONS, COMMUNICATION TOOL PRESCRIPTIONS OR BETWEEN HEALTH REFERRALS FOR TREATMENT PROFESSIONALS. BE WRITTEN LEGIBLY AND INDELIBLY. written legibly IT ALLOWS FOR CONTINUITY IT IS ESSENTIAL THAT OF CARE. RECORD ENTRIES CAN BE READ. Handwriting Standard of handwriting also requirement If care is initiated through a care plan and of duty of care towards a patient. harm results because others could not read your writing then liability in negligence is likely to arise.  Reliable Clear C- Unambiguous Free from jargon Consistent Free from Free from meaningless abbreviations or subjective phrases  ‘challenging’, Subjectiv ‘aggressive’, ity of words ‘happy’, ‘unwell’ Incomplete tasking 6th Oct 2016 Sister A.M. Smith Progress entry 10.00am Dave upset. DNA physio Reluctant to have dressing changed. Complaining of being flushed Rx 2 paracetemol Swab taken. 6th Oct 2016 Sister A.M. Smith Progress entry Arrived 10.00am 10.25 Departed 11.15 Dave upset this morning. “I am so fed up my backside is killing me”. Physiotherapist cancelled her appointment with him. Reported he was eating better but the wound on his backside was still sore. “Cold all night and now I feel hot and bothered”. Explained to Dave that his symptoms could indicate an infection and he consented to examination of his pressure ulcer. On examination the pressure ulcer had an increased level of offensive exudate and the wound edges were inflamed. Temperature was recorded aurally at 40c and his pulse was 100bpm. Wound swab taken with consent for culture. Dave advised to take 2 x 500mgs paracetamol tablets every 4 hours to reduce his temperature. Advised to drink at least 8 glasses of cold fluids throughout the day. Due to the infected wound, visits will now be daily. Next visit arranged for 7th Oct 2016 between 10.00 and 10.30. Structure of progress notes Reason For the visit and where, when it took place Observation Who was present and what did you see, find, discover from examination or assessment What were the persons concerns Intervention What did you do and discuss To who or with who Analysis What conclusions did you come How does it relate to previous entries, evidence, previous opinion Plan What are you going to now Clarity of language “ I do not intend to address the couple's relationship suffice it to say it is imbued with ambivalence : both having many commonalities emanating from their histories that create what could be a long lasting connection or alternative relationship that are a reflection of this. Such is this connection they may collude to undermine the placement."  " due to [mum’s] apparent difficulties identifying the concerns , I asked her to convey a narrative about her observations in respect of [dad]'s and [baby]'s relationship." Records Must Be Accurate Point in time The record should be dated and timed using the 24hour clock – day/month/year format. - 14:00hrs 24/06/2009. Normally be recorded in chronological order of when the care/treatment/intervention happened. Author Signed with the professional's name printed legibly underneath the signature together with their position. Initials for entries must not be used as it is vital to be able to identify the member of staff if a complaint is made. Alterations Never delete a record Do not score out so as to make entry illegible All alterations must be made by scoring out with a single line that does not completely obscure the error. Correcting fluid must not be used.  Complete All sections of the record must be completed If a section is not relevant say why If the patient's condition remains the same say so. Be careful of arbitrary ambiguous entries In one case a record entry stated, "6.30am sleeping peacefully, 8.40 am dead"(Wright 2003). In the cold light of a courtroom such an entry makes it look like the patient was not being properly monitored.  Temptation to use jargon and abbreviations as a form of professional shorthand is compelling. Records Risk of miscommunication must be increases dramatically by using this shorthand. clear Combination of shorthand instructions and poor handwriting lead to the death of a patient.  Must ensure that all colleagues and service users have a clear understanding of entries within their records. Use of The general rule is that abbreviations should not be used in clinical records. abbreviatio ns within Some abbreviations (where the full term is lengthy) may be used only after the term is written in full for clinical the first time, with the abbreviation placed in brackets immediately following e.g. Methicillin- records Resistant Staphylococcus Aureus (MRSA). The abbreviation should be for that specific entry only and a term generally recognised within the National Health Service. What do these abbreviations mean? PRN LOBNH OD TEETH ROM PDE DIB PFO HTN TBP IN LOL TOF UBI  Clinical records must be recorded as soon as possible after an event has occurred Providing current information on the care and condition of the T- patient. If there is a delay the reasons for the delay must also be recorded Timely Retrospective entry must be clearly identified in the record Be written, wherever possible, with the involvement of the patient, carer or parent  Records are key communication tool S- Essential for effective patient care that records are used Shared and communicated. Where tragedy occurs the resulting inquiry report repeatedly cites a failure of communication as a cause. Five Minute Appraisal Incomplete Fact or Communication? Tasking supposition? Is the entry Wherever an Failure of complete? opinion is communication Have you shown expressed it underpins that you have should have a litigation discharged your factual basis. Will the record duty of care Need to entry be clearly Often only recognise what is understood by describe half of a fact and what is those who read what you did. a supposition it? Consent taken May have to Vaccination expand certain given entries so that Risks everyone explained understands what you mean. Abbreviations Remember What you write Records are never does matter neutral They will either Take great care support you or when writing your condemn you records