Introduction - Record Keeping in Nursing: Standards & Legal Aspects
Keeping detailed information about the patients, their physical conditions and ongoing treatments represents record-keeping in healthcare. Record-keeping is a method of organising the huge pile of documents involved in a healthcare setting. The medical record officer or a health information clerk is primary responsibility for record keeping. However, since the documents are used by every profession in the setting, it is a part of every member’s duty to maintain them. The report has shed light on the concept of record-keeping and its role in contemporary nursing. The importance of record-keeping in therapeutic relationships has also been a part of the discussion.
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Efficient record-keeping contributes to care assessment and decision-making about ongoing care. The Nursing and Midwifery Council (NMC) has set a code which mentions record keeping as an obligation of every nurse and that they should consider it an important part of their profession (Nmc, 2023). The 10th professional standard of the NMC code has highlighted the principles of record keeping.
10.1: It has been mentioned that the professional has to complete the records at the time of or immediately after the completion of an event.
10.2: Any arising problems need to be identified such that the colleagues using the same record have access to all the information.
10.3: The records need to be completed accurately, avoiding falsification and actions need to be taken in case anyone has not followed this requirement.
10.4: It is necessary to take full credibility of any patient data being entered and it has to be made sure that they are clearly written, without the use of unnecessary jargon, abbreviations or speculations.
10.5: It has to be ensured that the records are secure.
10.6: The collection, storage and handling of the data have to be appropriate.
Standard 18.2 mentions adhering to the guidelines while advising control drugs and recording the prescription, supply and administration of these drugs (McCarthy et al. 2019). Standard 23.1 has highlighted that it is necessary to cooperate with the audits of the training records and registration records.
Record keeping is all about patient data which is personal information and hence required confidentiality. As mentioned by Adams, (2019), the police authorities or the court has the authority to summon the medical records as a part of the law process. The limitation Act has limited the confidentiality of the records to 3 years. After the completion of this period, the court and law would not be responsible for the leakage of any information. Another legal obligation that might arise in the matter of record keeping is the consent of patients. The Data Protection Act provides the right to every individual to demand the confidentiality of their private information (Rcn, 2023). This poses a challenge for healthcare professionals who cannot proceed without treatment options unless patient information is available. Another possible issue might arise when patient information is being used for research purposes. The consent of the hospital authority would not matter in case the patients themselves do not accept the information being shared.
Examples of record-keeping
Verbal
One of the primary examples of records that are shared verbally is patient handovers, which implies passing the patient information when they are being handed over from one professional to the other. As said by Edelman et al. (2020), ideal handover information must include the medical record number, diagnosis, symptoms, test results, scheduled tests, care plan, fall risks, catheter and vitals. Multidisciplinary team meetings or MDT are other forms of verbal records where the professionals gather once a week or month to discuss individual cases. The proceedings are often recorded such that they could be referred for complicated cases in the absence of the assigned doctors.
Non-verbal
The most common form of non-verbal communication in the hospital setting is the written record of a patient. Every important information about the patient starting from the family history, vitals, ongoing medications, medical conditions and ongoing treatment is listed in these documents that are kept in a separate file with the patient ID (Karlsson et al. 2019). The care plans of the patients are another form of non-verbal record where the ongoing treatment and the support given to the patient are presented. Referrals might be considered another form of non-verbal record in which detailed patient information is listed before referring the patient to another professional.
The dependence on technology has enhanced with time and electronic records have been chosen as the alternative to paper documents in every field. In the healthcare setting, EHR or Electronic Health Records are the primary forms of electronic data which is the digital form of the health information of the patient (Digital, 2023). Another form of electronic record is EMR or Electronic Medical Records which is similar to EHR except for the fact that it includes the patient chart. Besides, care plans and medications and other forms of handwritten documents are mostly available in digital forms now.
Impact of record keeping on the development of a therapeutic relationship
Holistic/individualised care
A therapeutic relationship is a term given to the relationship developed between the patient and the healthcare professional. As per the 2nd standard of the NMBA professional nursing standard, a nurse is required to maintain an effective therapeutic relationship to allow the patient (Nursing, 2023). This is a part of the responsibility of every healthcare professional because it would allow the patients to convey every bit of their discomfort and make the treatment process much more effective. A part of a therapeutic relationship involves keeping track of every little change in the health condition of the patient and this is why record-keeping is necessary. In case the condition of the patient deteriorates, the professional is required to record that immediately and convey that to the seniors (De Groot et al. 2019). Record keeping is a part of ethical practice in healthcare and it enhances the therapeutic relationship by making the patient gain trust in the healthcare system.
Family Centred Care
Family Centred Care is an approach to a partnership between the family of the patients and the healthcare system. As said by Higgins et al. (2019), a care plan provided to the patient needs to be family-centred to assure that the family approves of it. It reduces the stress and the chances of conflicts and the communication between the patient family and the healthcare are enhanced, which minimises the chances of lawsuits. Record keeping is important in such a care plan because it would allow the patient's family to access the complete treatment plan of the patient (Transform, 2023). Besides, a healthcare setting keeping a record of every little diagnosis and intervention they provide to the patient gains the trust of the families more easily.
NHS values
The values listed under the NHS constitution include collaborative working, respect and dignity, compassion, commitment to care quality, improving the lives and that every life counts. Record keeping is a crucial requirement in collaborative work because it helps to maintain communication between professionals (Nhs. 2023). For example, a professional being handed over a patient needs to have every little record that the colleague who has been previously dealing with that patient, provides. On the other hand, respect, dignity and compassion are personal values which are enhanced when a professional realises the value of each patient’s life (Su et al. 2020). These realisations are gained in the process of record keeping because the professional gets to know how a minor medication or care plan can improve the quality of life.
Professional behaviours
Apart from therapeutic relationships, a professional is also supposed to display professional behaviour within the healthcare setting. As opined by Olivares Bøgeskov & Grimshaw-Aagaard, (2019), record-keeping is a major responsibility of healthcare professionals and hence it is also a part of professional behaviour. It falls under the ethical responsibility of every professional to keep and maintain patient records. Also, keeping the records assures that their lives matter and that enhances their trust in the healthcare setting (Adams, 2019). Record keeping helps an individual in the healthcare setting to improve their analytical skills which is why it is crucial for professionalism.
Conclusion
Record keeping is a major responsibility of every healthcare professional since it allows them to keep track of the patient’s health. Although medical record officers and health information clerks are mainly responsible for record-keeping, it is the duty of every other professional to maintain them. The Nursing and Midwifery Council (NMC) has set out separate standards in its code dedicated to record-keeping where every professional principle required in record-keeping has been listed. Legal issues are certain in the context of record keeping because it involves the confidential information of patients. Patient handovers and multidisciplinary team meetings are types of verbal record-keeping while written records, care plans and referrals come under non-verbal record-keeping. Considering the increasing dependence of humans on technology, almost all of these forms have become electronic. Apart from that, EHR and EMR are the two main forms of electronic record-keeping. Based on the evaluation, it might also be concluded that record-keeping is an integral part of therapeutic relationships considering the aspects of holistic/individualised care, family-centred care, NHS values and professional behaviours.
References
Journals
Adams, A. J. (2019). Transitioning pharmacy to “standard of care” regulation: Analyzing how pharmacy regulates relative to medicine and nursing. Research in Social and Administrative Pharmacy, 15(10), 1230-1235. https://doi.org/10.1016/j.sapharm.2018.10.008
De Groot, K., Triemstra, M., Paans, W., & Francke, A. L. (2019). Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews. Journal of advanced nursing, 75(7), 1379-1393. DOI : 10.1111/jan.13919
Edelman, L. S., McConnell, E. S., Kennerly, S. M., Alderden, J., Horn, S. D., & Yap, T. L. (2020). Mitigating the effects of a pandemic: facilitating improved nursing home care delivery through technology. JMIR aging, 3(1), e20110. doi:10.2196/20110
Higgins, A., Downes, C., Varley, J., Doherty, C. P., Begley, C., & Elliott, N. (2019). Supporting and empowering people with epilepsy: contribution of the Epilepsy Specialist Nurses (SENsE study). Seizure, 71, 42-49. https://doi.org/10.1016/j.seizure.2019.06.008
Karlsson, A. C., Gunningberg, L., Bäckström, J., & Pöder, U. (2019). Registered nurses’ perspectives of work satisfaction, patient safety and intention to stay–A double?edged sword. Journal of nursing management, 27(7), 1359-1365. DOI: 10.1111/jonm.12816
McCarthy, B., Fitzgerald, S., O’Shea, M., Condon, C., Hartnett?Collins, G., Clancy, M., ... & Savage, E. (2019). Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review. Journal of nursing management, 27(3), 491-501. DOI: 10.1111/jonm.12727
Olivares Bøgeskov, B., & Grimshaw-Aagaard, S. L. S. (2019). Essential task or meaningless burden? Nurses’ perceptions of the value of documentation. Nordic Journal of Nursing Research, 39(1), 9-19. DOI: 10.1177/2057158518773906
Su, J. J., Masika, G. M., Paguio, J. T., & Redding, S. R. (2020). Defining compassionate nursing care. Nursing ethics, 27(2), 480-493. https://doi.org/10.1177/0969733019851546
