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Clear, concise record-keeping is a vital part of good patient care, explains Jane Redfern Jones
Patient records are kept for three reasons - as a diary of the patient's journey, as a means of communication between those involved in the patient's care and as evidence in the event of a complaint or investigation into standards of care.
Anything written in relation to your work as an employee becomes a public record and under the Data Protection Act 1998, patients can apply to see what has been written about them. In deciding what and how much to write in a patient's record, a guide is to ask yourself: if I were caring for this patient for the first time, what would I need to know?
Write meaningful statements: comments such as 'patient slept well' or 'as per care plan' are not helpful. Also avoid vague phrases such as 'appears unsteady' - either the patient is or is not unsteady.
Do not mistake assumption for fact. For example, rather than 'the patient fell over', write: 'I found the patient on the floor in a position consistent with a fall'.
As a rule, abbreviations should be avoided. A number of universally accepted everyday medical abbreviations are used appropriately and safely, such as BP (blood pressure) and HR (heart rate). Writing these in full each time would considerably increase the time taken to complete records.
The key principles for quality record-keeping are outlined in the 2009 Nursing and Midwifery Council (NMC) guidelines. Although these were aimed at registered nurses, much of the information applies to all contributors to patient records.
Although record-keeping can be viewed as a chore that gets in the way of looking after a patient, you must allocate time for hands-on care and documentation because the two together constitute total and quality patient care.
Good record-keeping can be summed up by saying that anything you write must be honest, accurate and non-offensive and must not breach patient confidentiality.
Follow these rules and your contribution will be of value.