Analysis

Record-keeping and documentation in nursing: how to get it right

Patient records act as a vital communication tool that helps ensure safety. Find out how to ensure yours are accurate and appropriate, and support your practice

Patient records act as a vital communication tool that helps ensure safety. Find out how to ensure yours are accurate and appropriate, and support your practice

  • In 2021-2022, poor record-keeping was cited as the ‘level one’ allegation in 14% of proven fitness to practise cases heard by the Nursing and Midwifery Council
  • Patient notes should be succinct, factual and completed as you go along, experts advise
  • Tips for good record-keeping and a case report from a NMC fitness to practise case involving poor record-keeping

Poor record-keeping features consistently in concerns raised with the Nursing and Midwifery Council (NMC) about registrants’ conduct.

According to the NMC’s Annual Fitness

Patient records act as a vital communication tool that helps ensure safety. Find out how to ensure yours are accurate and appropriate, and support your practice

  • In 2021-2022, poor record-keeping was cited as the ‘level one’ allegation in 14% of proven fitness to practise cases heard by the Nursing and Midwifery Council
  • Patient notes should be succinct, factual and completed as you go along, experts advise
  • Tips for good record-keeping and a case report from a NMC fitness to practise case involving poor record-keeping
Picture: iStock

Poor record-keeping features consistently in concerns raised with the Nursing and Midwifery Council (NMC) about registrants’ conduct.

According to the NMC’s Annual Fitness to Practise Report 2021-2022, the top three categories of allegations upheld at adjudication have remained the same since 2019, in varying order: patient care, prescribing and medicines management, and record-keeping.

Accurate, appropriate documentation

In 2021 record-keeping was cited as the ‘level one’ allegation in 14% of proven cases. Although the numbers are small – there were in total 414 fitness to practise decisions made – it is clear that getting documentation wrong has the potential to end careers.

So how can you ensure that the notes you write, often at the end of a long shift, are accurate and appropriate?

‘Record-keeping’ has changed considerably since the days when nursing notes were always written by hand and filed in dog-eared ring-binders, and those written by other healthcare professionals were kept in separate places.

Digital or electronic record-keeping has enabled a far wider range of information to be accessed via single platforms, giving multiprofessional teams the capacity to record and read assessments, test results, radiology images and much more.

Picture: iStock

‘When I came into the profession in 1995, record-keeping was all handwritten,’ says De Montford University associate dean (academic) of the faculty of health and life sciences Nicola Brooks.

‘That’s changed significantly and now it’s any communication that happens regarding a patient, whether that’s a text message, for example, or an email.’

The importance of being succinct

Handwritten notes may still prevail in some pockets of healthcare, she says, but the drive towards electronic record-keeping has been gathering pace for years.

However, the principles are the same regardless of whether you are recording your notes on paper or on a tablet, says Dr Brooks, and key among them is the need to be concise.

‘I’ve worked with practitioners over the years who have written reams and reams – but it’s what I would call unnecessary fluff. You need to recognise that if you do this, the next person reading your record has a lot to get through.’

‘If you’ve looked after a patient for 8-12 hours, can you genuinely remember what happened at eight o’clock that morning when you’re trying madly to fill in your records before you go home?’

Nicola Brooks, associate dean (academic) of the faculty of health and life sciences, De Montford University

RCN head of nursing practice Wendy Preston agrees that brevity is best. ‘Always write in a way that is clear, accurate and concise,’ she says. ‘You need to be able to write less but ensure it’s of high quality.’

Getting record-keeping right comes with experience, says Ms Preston, a consultant nurse who also works as an advanced nurse practitioner for NHS 111, where call-handlers’ documentation is regularly audited, with feedback provided.

Regardless of experience, adopting a standardised, systematic approach to record-keeping can help all nurses, she suggests. That might include documenting the presenting complaint and its history, the patient’s health background and any other considerations, plus details of your assessment and examination.

‘Safety netting’ and legal protections

In Ms Preston’s NHS 111 role, ‘safety-netting’ is also important. What has the patient been told about when to call back or when to call an ambulance? When should they expect to feel better? ‘I need to summarise all of that in my documentation,’ she says.

The reasons why all this matters so much are obvious: concise, accurate documentation facilitates better care. Nurse B, taking over from Nurse A, can see from the records that the patient’s wound has been dressed, medication changed and discharge home arranged.

But there are other reasons why record-keeping is so important, besides the threat of an NMC fitness to practise hearing if it is alleged to be below standard. In its guidelines on record-keeping, NHS Professionals stresses the important legal aspects of accurate documentation. ‘The approach to record-keeping that courts of law adopt tends to be that “if it is not recorded, it has not been done”, the guidance says. It adds that nurses’ records can be called as evidence in:

  • Coroners’ courts or criminal proceedings.
  • Safeguarding and local authority investigations.
  • Serious incident investigations by trusts.

‘Good record-keeping shows how decisions related to patient care were made, while poor record-keeping increases the risk of harm when making decisions,’ the guidelines note.

Good record-keeping: what should you include – and what should you leave out?

NMC senior nursing education adviser Sue West says: ‘High standards of reporting are something we expect from all nursing professionals on our register. This means covering the what, where, when, why and how of someone’s care. It may also include identifying any risks or problems that arise and detailing the actions taken to deal with them. You should make sure your notes are clearly written, dated and timed, and don’t include unnecessary abbreviations, jargon or speculation.’

The NMC standards of proficiency indicate that records should also be timely, Ms West adds. ‘For instance, if you don’t record when you administered a drug, colleagues might assume you haven’t done so. This might lead to an overdose. That’s why the Code guides you to complete records at the time or as soon as possible after an event.’

Record-keeping is covered in section 10 of the NMC code, where registrants’ responsibilities are laid out in six clear clauses (see box).

Good record-keeping: what the Code says

The Nursing and Midwifery Council’s code says registrants should:

Picture: johnhoulihan.com
  • Complete records at the time or as soon as possible after an event; if the notes are written some time after the event, make a note of this
  • Identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need
  • Complete records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements
  • Attribute to yourself any entries you make in any paper or electronic records, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation
  • Take all steps to make sure that records are secure
  • Collect, treat and store all data and research findings appropriately

Write up notes as you go, rather than falling into the unpaid overtime trap

Proper record-keeping matters because it enhances care and safety, communicates to others a patient’s progress or deterioration, and ensures nurses are practising in line with their professional responsibilities.

But a paradox exists in practice: despite its undoubted importance, record-keeping in nursing is often an add-on, something completed in a last-minute flurry after the event and as a prelude to going home after a shift. When it comes to the factors that can affect the likelihood of proper record-keeping ‘the biggest thing is time’, says Ms Preston.

She cites the RCN’s ‘last shift’ survey conducted in early 2022, which found that only 18% of the tens of thousands who responded felt they had enough time to provide the level of care they would like to. Respondents said only a quarter of shifts had the planned number of registered nurses.

‘It can be half an hour, up to two hours every day, that nurses are working unpaid,’ Ms Preston says. ‘And when we’ve looked at all that unpaid overtime, it’s mainly for record-keeping. Nurses don’t go home until they’ve done it. They simply do not have the time for record-keeping in their day-to-day working pattern, whether in the community, on the wards or in a nursing home.’

She says there are clear consequences for nurses’ health and well-being because they are regularly staying late to finish their documentation.

The answer, Ms Preston says – and as the NMC recommends – is to write up notes as you go. ‘But that can be difficult when you’ve constantly got one emergency after another.’

Dr Brooks agrees that, where possible, contemporaneous notes are best. ‘Don’t leave it all until later,’ she advises, ‘You can be more concise if you’re working in real time and it’s actually quicker. You can provide the facts and move on. It helps your memory as well. If you’ve looked after a patient for 8-12 hours, can you genuinely remember what happened at eight o’clock that morning when you’re trying madly to fill in your records before you go home?’

And be aware that writing up notes at the end of a long shift increases the likelihood of errors.

Staying late to finish notes affects nurses’ health and well-being, and can also increase the likelihood of errors PIcture: iStock

Act quickly to address record-keeping errors

While mistakes in record-keeping are understandable, covering them up is not. If you do make a mistake, Dr Brooks says, best practice is to make any necessary amendments quickly and in line with local policy. And always make sure you write records yourself. ‘Don’t get someone else to do it for you.’

Record-keeping should be viewed as a communication tool designed to enhance patient care by sharing key information, not as an inconvenience you undertake mainly to keep investigators off your back – and, as Dr Brooks points out, should your practice ever be subject to scrutiny, documentation done properly will protect your career and reputation, not damage it.

Good documentation can support you

She cites a case she uses in teaching where an investigation into a patient’s death centred on whether nurses had been told by a medic to begin a particular procedure. The nursing notes confirmed that the nurses had been given the go-ahead, while there was nothing recorded in the medical notes to indicate otherwise. Effectively, the doctor was trying to blame the nurses.

‘It was the nurses’ record-keeping that laid out the facts and supported their practice,’ she says. ‘So in some senses, yes, your record-keeping can come back to haunt you, whether through an internal disciplinary, a patient complaint, or if it ends up at the NMC. But the message really needs to be the other way round: your records can support you.’

Case report: when poor record-keeping amounts to misconduct

NMC hearing (posed by models) Picture: iStock

Notes from Nursing and Midwifery Council (NMC) panel hearings into allegations of misconduct demonstrate that it is not only actual harm caused to patients by inadequate record-keeping, but the potential for harm, that can lead to sanctions.

In a case heard in August 2022, involving an NMC registrant employed as a registered nurse in a care home, 11 charges related to failures in record-keeping, specifically that the registrant did not document ‘any or sufficient detail’ about care provided for a resident’s necrotic heel.

In its judgement on the case, the panel said: ‘The panel considered that the registrant had applied the bandage to Resident B’s necrotic heel, but she subsequently failed to inform anyone about this within the medical notes.

‘There is no suggestion that the treatment she provided was anything other than appropriate, so the panel considered this purely a failure in respect of documentation.

‘However, as she did not document her treatment in Resident B’s notes or hand over the information to another member of staff, there was potential for it to have been missed by other staff in the future, and therefore placed the patient at risk of serious harm as the wound could have deteriorated further.

‘Therefore, the panel considered that this amounts to misconduct.’

A similar decision was reached on all other charges and the registrant was struck off.


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