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Contemporaneous notes of a Nurse

Ask the importance of one minute from a game show participant, ask the value of one second from the person who just avoided an accident and ask the value of one micro second from the sprinter who just lost a race. Similarly, ask the importance of a missing number in a nursing note from  a patient who was given the wrong dose and had a near death experience as a result. The job of a nurse, therefore, comes with a lot of responsibilities and obligations.

A nurse has to deal with a number of patients in a day, keep track of their treatments, findings of the diagnosis and schedule of their medicines. Therefore, it becomes binding on them to make notes, also called as contemporaneous notes to log day to day condition and treatment of a patient. Contemporaneous means ‘recorded at the time’. To remember each and every patient’s illness, what medicine has already been given and what medicine needs to be  given next, is not humanly possible for a nurse. Hence, maintaining contemporaneous notes helps her/him in remembering the details, which she/he can refer when visiting the same patient in the next round. Any mismatch in detail can lead to wrong medicine which may cost someone his life. In one such case of negligence, in 2002 a nurse was relieved from her duties by Nursing and Midwife Council, UK, following a decision by the Competence and Conduct Committee. During the inquiry it was found that the nurse failed in her duties in keeping accurate log of a patient related to his diabetes, pain management and food. She was found guilty of misconduct and barred from her duties. The job of a nurse is very demanding and draining, but that in no way should be a reason to impede a nurse from preparing accurate contemporaneous notes.

Thorough contemporaneous records maintained by a nurse serve as an important useful and management tool for all the members of the team taking care of a patient. The treatment and health care of a patient is not just one person’s duty. It is the combined effort of the doctor, nurse, health visitor, physiotherapist, etc., all of whom may not be available at the same time. Hence, contemporaneous notes maintained by a nurse, who is taking care of the patient, maintain the continuity of the care and keep everyone in the loop. Before making any recommendation to the patient, these contemporaneous notes should be referred, so that accurate treatment is imparted. In absence of a nurse who prepared these notes, these contemporaneous notes can be referred by other nurses, as nurses work mostly in shifts.

All the information recorded about the patient should necessarily be written at the time of the event or as soon as possible, so that accurate and chronologically precise records of event are noted down. While it is understood that these notes are made only after an event, but it is advisable to make them while the events are still fresh in the memory of a nurse, so that these notes are likely to be more accurate, if challenged.  If a nurse make these notes in retrospect then there is a possibility that some details may have faded from the memory. In that case, it is recommended to remember as minute details as one can and jot them down in a notebook. While keeping these notes, a nurse should take special care of a few things that include vital signs, change of shifts, allergies, physician’s orders and medication orders. These notes must be duly signed along with date and time by the nurse. One should avoid making any subjective suggestions and personal opinions and should stick to writing exactly what is heard and seen. A nurse must report any critical signs to the doctor within 30 minutes, in case the signs are not in sync with the contemporaneous notes.

According to NMC guidelines, the contemporaneous notes of a nurse should be fact-based, correct and consistent with the events. They should be written as soon as possible and should provide up to date information about the treatment and condition of the patient. They should be written such that the content of these nursing notes cannot be erased or obscured. Any changes or additions made in these comprehensive notes should be properly dated and timed, and duly signed by the concerned person, so that original writings are clear. They should not include any abbreviations, jargon or phrases that cannot be understood. They should not contain any speculation based on personal views or unpleasant statements. A well-written contemporaneous note can be readable on any photocopies. These guidelines also mention that these nursing notes should identify the actions that have been taken place during the course of the treatment in a consistent manner, such that they can be understood by anyone. They should have full information about the planned treatment, the diagnosis and the decisions made and the care delivered.

These nursing notes are vital as they comprise the exact reality of the proceedings within which the services were offered to the patient. If these notes have to be produced in front of the court during any investigation, they should have an accurate account of the event, as they play a vital role in such proceedings. There have been cases wherein, due to incorrect contemporaneous notes submitted by a nurse, stern actions have been taken against the accused. In case of absence of appropriate nursing notes also, the ruling is generally in the favor of the patient. For e.g., in the case of  Brown v. DeKalb Medical Center, a case that came before the Georgia Court of Appeals, a patient claimed that he, allegedly, acquired pressure ulcers at DeKalb’s nursing facility which led to below-the-knee amputation of the patient’s left leg. Although, the ulcers had been treated properly at the nursing facility, the nurse failed to document that adequate services had been provided to that patient. The court reject DeKalb’s appeal on the ground that the absence of documentation of the ulcer was not the same as documentation of a thorough skin assessment. The decision went in patient’s favor and damages were awarded.

Prior to 1970, notes made by the nurses were not taken as legal evidence in the court of law. In case evidence was in demand, the nurse was presented to testify the truth of the contents of the notes. But in 1970, in the Ares v Venner case, the Supreme Court of Canada, for the first time, considered the nurse’s notes as an acceptable evidence. Courts rely on a nurse’s notes to reconstruct the events, confirm the dates and time to resolve a conflict in health care related cases. In one of the lawsuits, a judge stated that,” nurses’ notes must form the basis or starting point for an emergency room doctor’s opinion, and of course the treatment he subsequently renders.”

Considering that it may takes months or even years before a case appears for trial, nurses can’t just rely on their memory to summon each and every detail about the patient. They do not possess superhuman abilities. Detailed contemporaneous nursing notes, therefore, become a savior as a means of recollection for litigation purposes. If there was no document, there was no evidence. In the case of Kolesar v. Jefferies, presented before Supreme Court of Canada, a patient was found dead in his room, post-operation. The medical chart was referred to establish liability, but there were no entries by any nurse for the past 7 hours. In the absence of documentation, the court inferred that “nothing was charted because nothing was done”. If a nurse was obliged to attend the patient and failed to chart the act, the court is allowed to infer that the act was not performed.

No attempt should be made to ‘cover one’s deeds’ by altering or substituting the original record in a contemporaneous notes of a nurse. Poor record keeping can make it difficult for the follow up nurse to provide the right medication to the patient which can lead to serious implications. This can lead to a lot of confusion as well as can cause mistrust in the mind of the patient and his family, who have entrusted his life in the nurse’s hands. Ill maintained nursing notes bring a bad name not only to the nurse, but also to the hospital and can lead to serious complaints. Any serious consequence of bad note keeping can lead to expulsion of the nurse or in worst case, blacklisting of the hospital.

It is therefore, absolutely necessary for a nurse to maintain the contemporaneous notes so as to maintain the continuity in the treatment.  Electronic documentation is also sometimes favored but it has a high risk of breach of confidentiality. A whole lot of information is lost if these notes are not taken contemporaneously and can lead to dire consequences. Hence, the nursing notes become an indispensable part of the treatment of a patient.

REFERENCES:

Canadian nurses protective society,. (2007). Quality documentation: Your best defence. Retrieved on August 19 2015, from  http://webcache.googleusercontent.com/search?q=cache:NRzQq6JxhPcJ:www.cnps.ca/index.php%3Fpage%3D85+&cd=3&hl=en&ct=clnk&gl=in

College of registered nurses of British Columbia,.  Nursing Documentation. Retrieved on August 19, 2015 from  https://www.crnbc.ca/standards/lists/standardresources/151nursingdocumentation.pdf

e-law resources,. Kent v Griffiths [2000] 2 WLR 1158 Court of Appeal. Retrieved on 19 August, 2015, from  http://www.e-lawresources.co.uk/Kent-v-Griffiths.php

Nurse Together,. (2012). 17 tips to improve your nursing documentation. Retrieved on 19 August, 2015, from http://www.nursetogether.com/nurse-documentation-helpful-tips-every-nurs

Nursing documentation, record keeping and written communication, from https://www.us.elsevierhealth.com/media/us/samplechapters/9780443073991/9780443073991.pdf

Advanced Nursing Practice Toolkit,. (2008). Documentation and Record Keeping. Retrieved on 19 August, 2015, from http://www.advancedpractice.scot.nhs.uk/legal-and-ethics-guidance/documentation-and-record-keeping.aspx

Judgments of the Supreme Court of Canada, Supreme Court of Canada, Ares v. Venner, [1970] S.C.R. 608, Date: 1970-04-28. Retrieved 19 August, 2015, from

https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/6235/index.do

Fastaff Travel nursing,. (2014). Tips for writing quality nurse notes. Retrieved 19 August 2015, from  http-http://www.fastaff.com/blogs/tips-writing-quality-nurse-notes

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