Record-Keeping in Nursing.
The NMC (2008) state that record-keeping is fundamental in nursing practice. Accurate record-keeping ensures effective patient care and protects their welfare by promoting consistency of care (Spouse et al. 2008). The NMC (2008) introduced Essential Skills Clusters 2010 (NMC 2010) to pre-registration nursing which conveys that communication must be effective, both orally and in writing so that the meaning is always clear. Dougherty and Lister (cited by Hutchinson 2006) also identify that language used should be in a way where the patient can understand it.
In support, the NMC (2008) stress that information should be accurately recorded without jargon or abbreviations and that our handwriting should be legible on written records. The work of Cowen (2010), ‘Dyslexia, dyspraxia and dyscalculia: a toolkit for nursing staff’ discovered in one university that fourteen per cent of nursing students were diagnosed with dyslexia or dyspraxia. Dyslexia can cause problems with spelling; writing clearly, accurately and can therefore create difficulties for others accessing information.
The NMC code of conduct (2008) expects practitioners to manage themselves efficiently and to understand and know their limits. There have been various investigations and studies linked to poor record-keeping, one of which was outlined by Fisher (2001). The data collected from recently discharged patients in the Newcastle Upon Tyne NHS trust revealed problems in incorrect patient identification, incomplete documents and missing documents.
Similarly a project analysing documentation across Barking, Havering and Redbridge Hospital Trust identified problems in lack of patient involvement (O’Connor, 2007). This issue breaches the NMC code (2008), which states you should work with those in your care. Being honest and trustworthy in completion of records is outlined in the NMC code (2008), however a study by Taylor (cited by Spouse et al. , 2008) revealed that nurses have recorded positive outcomes in order to avoid legal, ethic and professional criticism.
Poor attitudes to record-keeping may result in a process to investigate nurses who fall short of the NMC code (2008) standard. Accurate record-keeping is important as it also protects nurses from legal dispute (Spouse et al. , 2008), yet many healthcare professionals view it as a chore (McGeehan, 2007). Furthermore Dimmond (cited by McGeehan, 2007) clarifies that record-keeping is not an optional extra and should not be pushed in at the end of a shift. The NMC code (2008), states that records must be competed as soon as possible.