Record-keeping guidance: 6 tips to make documenting your work easier
A staff nurse shares her tips for effective record-keeping
Staff nurse Georgina O'Reilly-Foley knows the benefits of documenting your work and shares her tips for effective record-keeping
One of the first lessons I was taught on my nursing course was the importance of documenting what we do at work.
This is vital in the emergency department (ED) where we move rapidly between patients with different presentations and diagnoses, giving medications, carrying out observations, providing personal care and delegating tasks.
Documenting all of this can feel like an impossible task to a newly qualified nurse in a ED but it is an essential part of our role, as set out in the NMC code of conduct.
I am passionate about this and during my two and a half years as a band 5 nurse on the ED I have devised some tips to help keep on top of records and ensure you are never caught out.
1. Retrospective documentation
If you forget to write something down, do not worry. Write your entry retrospectively including the approximate time the event happened and the time you wrote the entry.
2. Encourage healthcare assistants to write in the notes
Prompt your team to write in your patient’s notes. If a healthcare assistant changes your patient’s pad they can document this.
3. Write down what you didn't do
As well as documenting events that have happened, remember to write why certain aspects of care were not carried out. If no entry is made to justify why certain tasks were delayed it appears as if they were not attempted.
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For example, a doctor requests a laying and standing blood pressure, but in your view the patient is not safe to stand because their laying blood pressure is 80/49.
You could write in your records: ‘Standing blood pressure not carried out because patient’s laying BP is 80/49 so I am not happy to stand my patient at this time.’
4. Put yourself in a colleague’s shoes
When your patient is moved to a ward or assessment unit, your documentation is the only form of communication with that team. If you have not written much about your patient the next team will have to start from scratch, making their job much harder.
Omitted documentation can lead to problems, for example if no fluid input or output has been documented for a patient, the next team will assume there has been no fluid given or urine produced, which can suggest an array of issues.
5. Never document an event before it has happened
As tempting as it can be, never write that an aspect of care has been carried out before it has. For example, do not sign a drug chart before the drug has been given.
6. Don't be afraid of writing too much
My colleagues often giggle and ask whether I have finished writing War and Peace yet when I am filling in my patient’s notes. Your documentation is the only evidence you have to demonstrate how well you took care of that patient so if you want to write extensive notes, go ahead!
Georgina O’Reilly-Foley is a band 5 staff nurse at Southend University Hospital NHS Foundation Trust