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Set the record straight

Clear and accurate record-keeping is vital to support the effective delivery of care and defend against litigation, writes journalist Anna Scott. Is it being given the priority it deserves ?

In September the NMC’s Fitness to Practise Committee suspended a health visitor for six months following charges of misconduct and a lack of competence.

Among the facts proven at the hearing were that the health visitor, who was employed by NHS Greater Glasgow and Clyde, wrote a note on a specialist children’s services assessment document about an incident of child sexual abuse and filed it with the wrong family’s record card. 

The health visitor also did not include significant clinical information on a baby’s scan in a care plan, did not adequately document the results of a hearing test, and scored out progress notes were without explanation. 

The committee decided that the health visitor had, ‘through poor practice, put patients at risk of harm, brought the profession into disrepute, and breached fundamental tenets of the nursing profession’ (NMC, 2017). 

According to Jane Beach, lead professional officer for regulation at Unite, at least 25% of fitness-to-practise cases involve poor record-keeping as the primary referral or a secondary charge. 

The NMC’s code states that nurses across the UK are expected to keep clear and accurate records that are relevant to their practice (NMC, 2015a) (see panel opposite).

An NMC spokesperson says: ‘Record-keeping is a vital part of the delivery of safe and effective care for every nurse and midwife, whatever their scope of practice. The code clearly outlines that, to practise effectively, all nurses and midwives must keep clear and accurate records relevant to their scope practice, and that they must take immediate and appropriate action if they become aware that someone has not kept to these requirements.’

 

The current picture

So what are the reason’s behind poor record-keeping? Pen and paper can pose particular challenges. ‘When we need records from another base we have to fill in a piece of paper and send it through internal post,’ says school nurse Laura*, part of a team split across several bases, which all tend to keep paper records. ‘It can take days to get the records back,’ says Laura. ‘Often the records are misfiled and our admin team hands the request back to us, thinking we already have them, slowing things down further.’

It’s tricky to get a clear and accurate understanding of how many health visitors, school nurses and community nursery nurses are using pen and paper to keep records of their clients and how many are using technology – desktop, laptop, smartphone or tablet – because the way records are kept is usually set by trusts individually (NMC, 2012).

Anecdotally, paper and pen appears to be the norm. ‘I’ve worked with paperless records, and prefer them, but my current trust is entirely paper,’ says Laura.


The code

To achieve clear and accurate records, practitioners must:

  • Complete records at the time or as soon as possible after an event, recording if the notes are written some time after the event
  • Identify any risks or problems that have arisen and the steps taken to deal with them, so colleagues using the records have all the information they need
  • Complete records accurately and without any falsification, taking immediate and appropriate action if community practitioners become aware that someone has not kept to these requirements
  • Attribute entries in any paper or electronic records to the community practitioner, ensuring they are clearly written, dated and timed, without and unnecessary abbreviations, jargon or speculation
  • Take all steps to ensure records are kept securely
  • Ensure all data and research findings are collected, treated and stored appropriately.

(Source: NMC, 2015a)


 

Time pressures

These aren’t the only record-keeping problems that Laura faces. ‘If I send records back to file and then something else needs recording, I have to re-request records, which takes time. Or if they are misfiled I won’t receive them at all, because admin doesn’t check for them beyond the first slot that they looked in.’

Time is a big factor. ‘The system encourages me to see fewer children,’ says Laura. ‘We’re not allowed to use “progress notes” yet. From experience, this helps when you see a big family because you can copy and paste into siblings’ records.’

Jane Beach – who is often asked to run training on record-keeping for school nurse and health visiting teams – says that time is the most commonly reported difficulty in keeping records.

‘It is clear that when time for contacts and visits is determined, time to complete the records is not always included as an essential part of the care contact and not an “add-on”,’ she says. ‘The focus always seems to be on recording the key performance indicators!’

It’s not just about time, however, says Jane: ‘It’s interesting that when asked who taught the participants [on my training courses] about record-keeping it is always other practitioners, so of course the quality will depend on the skills of the teacher. As a result, poor practice can be perpetuated.’ 

 

The rise of technology

Difficulties and inconsistencies in relation to record-keeping have an impact on community practitioners’ day-to-day practice. ‘I feel like I am wading through treacle in order to perform basic nursing tasks,’ Laura says. ‘It affects my motivation and my timekeeping.’

She says the situation could be improved if paper records were moved to school nurses to manage or more administrators were in place, or the trust moved to paperless records. ‘We keep being promised “paper-lite” working,’ she adds.

Laura’s trust recently implemented the patients’ record system and software EMIS, but it is primarily designed for GPs, so ‘doesn’t really fit my team’s requirements’. 

‘We can’t even see which team has the biggest caseload because most referrals are inactive,’ Laura says.

Another issue is duplication – many trusts have both paper and electronic systems, so they have to input the same information in a number of places. ‘My experience is that most services either don’t have electronic systems yet or are in the process of switching and still have both,’ says Jane. 

‘I did some training with 25 school nurses in the Midlands who had been electronic for 10 years,’ she adds. ‘But they still reported that there were times when they couldn’t connect to the system or had a problem with their laptop, which means they have to go back to paper. There is some inconsistency in whether this then gets transferred to the electronic systems or scanned once the issue is resolved.’

Inconsistency in process is another problem, Jane says, and there is a need for consistent policy and training on what community practitioners should do in these kinds of circumstances.


The importance of good recod-keeping

  • Helps to improve accountability 
  • Shows how decisions related to patient care were made 
  • Supports the delivery of services 
  • Supports effective clinical judgements and decisions 
  • Supports patient care and communications 
  • Makes continuity of care easier 
  • Provides documentary evidence of services delivered 
  • Promotes better communication and sharing of information between members of the multiprofessional healthcare team 
  • Helps to identify risks, and enables early detection of complications 
  • Supports clinical audit, research, allocation of resources and performance planning 
  • Helps to address complaints or legal processes. 

(Source: NMC, 2012)


 

Fast followers

One issue is that investment in technology – what to buy or when to buy it – and policy on record-keeping is a matter for individual trusts, not central government agencies, and is dealt with differently across the devolved nations. 

For example, NHS Digital does not get involved in making any procurement-based decisions on record-keeping technology – they differ from organisation to organisation, a spokesman says. 

NHS England has the Global Digital Exemplars programme, which is funding seven mental health and 16 acute health trusts that are delivering exceptional care efficiently to help them ‘move forward digitally’, according to a spokesman for the organisation. These trusts will receive funding and international partnership opportunities over the next two to three and a half years (NHS England, 2016a).

The idea is that exemplars will share their learning and experiences with digital technology through partnerships with ‘fast followers’ – trusts that will support the spread of best practice and innovation and receive NHS England funding – to enable other trusts to ‘follow in their footsteps as quickly and effectively as possibly’ (NHS England, 2016a). 

This may mean sharing software or a common IT team, or adopting standard methodologies and processes (NHS England, 2016a).

This programme is part of the NHS Driving Digital Maturity programme, which has the goal of ensuring the NHS is paper-free at the point of care (NHS England, 2016b). 

For how the other home nations are treating record-keeping, see panel, Digital record-keeping plans across the UK

 

Best practice

But there will ‘always be a need to have a contingency for when the IT systems fail,’ Jane says. ‘Due to funding, organisations are not always able to invest in the best IT solutions, and my experience is that they do not always involve the practitioners that will be using them in the design – so there are complaints that systems are not suitable. This happens particularly when acute systems are transferred to community settings, which of course are very different. There is also huge variation in the systems used.’

So what’s the advice for practitioners? It’s very important to keep refreshing yourself on the fundamentals and to raise concerns when you feel managers are not allowing time to complete records. Jane recommends self-auditing records or auditing them as a team – reading each other’s records and discussing what action was taken and what the plan is. ‘The person who wrote them can then assess whether this is what actually happened/was planned.’

Jane also says that the fundamental principles of record-keeping should be taught during university courses – the scope of practice and what to write, how much and what content. She adds: ‘Poor record-keeping comes out time and again in serious case reviews, so should really have more focus than it does. It is important to remember that it is a part of the contact and not an add-on.’

Picture credit | Getty images


Digital record-keeping plans acros the UK

Northern Ireland

The eHealth and Care Strategy, published in 2016, sets out a range of measures for the increased use of digital technologies to support the delivery of health and care services up to 2020, and includes plans to ‘explore the potential for a fully integrated digital health and care record system’, according to the Department of Health (2016).

Scotland

The new Digital Health and Social Care Strategy 2017- 2020 will be published at the end of this year, encompassing a new eHealth strategy for the whole of the NHS – patients and workforce – across the country (Scottish Parliament, 2017).

Wales

Welsh health secretary Vaughan Gething announced in September a central government investment of more than £5.5m for digital priorities in the NHS in Wales. The money will be spent on projects including the Welsh Community Care Information System (WCCIS), which allows staff working in health and social care to use a single system and a shared electronic record of care (Welsh Government, 2017).

‘Roll-out of WCCIS will provide significant benefits to the work of frontline practitioners, particularly in reducing travelling time, improving the standard of document keeping, improved care planning compliance, reduced duplication in record-keeping and ultimately information being available to all practitioners involved, together with releasing time to care,’ a Welsh Government spokesman says.


References

Department of Health, Northern Ireland. (2016) eHealth and care strategy. See: bit.ly/2yYxgyK (accessed 12 October 2017).

NHS England. (2016a) Global digital exemplars. See: bit.ly/2xxZS0j (accessed 12 October 2017).

NHS England. (2016b) Driving Digital Maturity programme. See: bit.ly/2ig1QMb (accessed 12 October 2017).

NMC. (2017) Nursing and Midwifery Council Fitness to Practise Committee substantive hearing 5-8 September 2017. See: www.nmc.org.uk/globalassets/sitedocuments/ftpoutcomes/2017/sept-2017/reasons-finch-ftpcsh-51473-20170905-08.pdf (accessed 11 October 2017).

NMC. (2015a) The code: professional standards of practice and behaviour for nurses and midwives. See: nmc.org.uk/standards/code (accessed 27 October 2017).

NMC. (2015b) Standards of proficiency for nurse and midwife prescribers. See: www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-proficiency-nurse-and-midwife-prescribers.pdf (accessed 12 October 2017).

NMC. (2012) Record-keeping: guidance for nurses and midwives. See: www.southernhealth.nhs.uk/_resources/assets/inline/full/0/19026.pdf (accessed 13 October 2017).

Scottish Parliament. (2017) Technology and innovation in health and social care. See: bit.ly/2yYI4PI (accessed 12 October 2017).

Welsh Government. (2017) ‘If you want the best technology in the Welsh NHS, you have to invest in IT’ – Vaughan Gething. See: bit.ly/2A043U6 (accessed 12 October 2017).

 

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