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Nursing Record Keeping: The Importance of Contemporaneous Notes

In the ever busy schedule of a nurse, you might think that keeping records will distract you from the job of caring for your patients. That thinking is completely erroneous. Keeping contemporaneous records is an important aspect of the care you give to your patients. Even if you have an excellent memory, you might not be able to recollect everything that happened or everything you did during a shift. Your handover to the next nursing team will not be complete if you do not present accurate and clear records. This can negatively affect the welfare of your patients. Accurate, neat and careful patient records and documentation are the trademarks of a dependable and compassionate nurse. However, badly written nursing notes can create doubts regarding the quality of care provided by a nurse.

The Legal Angle

The law in several countries says that if an event is not recorded, then it has not happened. Thus, nurses have a professional and legal responsibility to keep proper records. As a nurse, you probably encounter new issues each day and make new decisions regarding patient care on a regular basis. As patients become more aware of their needs and rights, each decision you make can potentially be reviewed. Considering the hassle and stress of your work environment, you might regard contemporaneous notes taking as a task that obstructs patient care. Actually, it is an important aspect of care.

It is important that you allot time for caring for your patients and keeping records. This is because patient care is not complete if either one of them is missing. If you regard record keeping as an unpleasant task, then chances are that you will not keep accurate and clear documentation that’s expected of a certified nurse.

If, for example, you care for several patients each day, then it would be almost impossible for you recollect information regarding the care you gave to a particular patient several weeks or years later. Nevertheless, the patient who is making a complaint will likely have vivid recollections of the event as well as the circumstances surrounding the event. Thus, good contemporaneous notes taking can be an important means of recollection if you are faced with a law suit. During such circumstances, comprehensive evidence will likely be influential. Healthcare professionals with poor memories and who did not keep proper records of events might find themselves in a difficult position. A nurse giving evidence can easily and accurately relate what happened, if he or she has quality records to consult.

Before the case is heard in the law court, legal professionals would have read and studied the nursing notes. This would help them determine the professionalism and competency of the nurse in question. If the nursing contemporaneous notes are poorly written, then it can be deduced that the nurse did not care for the patient in a professional manner.

Always bear in mind that the records and notes you take while doing your work can potentially be utilized as evidence in court. If the notes are ambiguous, it might be difficult to prove that you acted professionally while performing your duty. The patient’s attorney will try to create doubts about your professionalism. If you are found negligent in such circumstances, you might end up losing your right to practice, even if you are certain you provided the right care.

Your Colleagues Depend on the Records You Keep

Another thing you should always keep in mind is that your colleagues depend on the notes you keep when they take over the care of a patient. Knowing this will help you resolve any ambiguity regarding the amount of information to record. The amount of information you record will largely be determined by local requirements as well as by your professional judgment. If you’re in doubt regarding what to record, you should ask yourself this question: What would another nurse need to know if he or she is taking over the care of my patient? After studying your notes, your colleagues should be able to carry on caring for the patient without hitches.

Also, bear in mind that you will be held accountable for any task you assign to unregistered staff. If, for example, you assign record-keeping to nursing assistants or students, you should ensure that they can perform the task adequately and that they are properly supervised.

Tips for Keeping Quality Nursing Records

The records you keep must contain detailed, objective, precise, current, however concise account regarding the patient’s hospital stay. The records can be hand-written or done electronically.

  • Date as well as sign every entry. Give the time, utilizing the twenty four hour clock system (For instance, instead of writing 3 pm, you should write 15:00).
  • Use a standardized form. This way, the records will be of high quality as well as consistent. Nursing care should be provided in a systematic manner and this must be recorded in a consistent manner. The record should include planning, implementation, as well as care assessment.
  • Make sure that each record has an identification sheet which contains the personal data of the patient: name, address, age, care giver, next of kin, and so forth. Be sure that the patient’s full name is contained in all continuation sheets.
  • Make sure that continuation sheets are readily available
  • If the record is to be hand-written, then be sure to write in ink and never in pencil. Also, do not expose the records to direct rays of the sun. This way, the records cannot be erased and will not fade.
  • When a new patient is admitted, record the patient’s blood pressure, visual acuity, respiration, temperature, pulse, and the outcomes of any examinations.
  • The problems that the patient is experiencing should be clearly stated as well as the diagnosis made.
  • Write down all pertinent findings and observations within the nursing record of the patient. These should also be written on any charts for example intraocular pressure phasing or blood pressure charts. After the patient has been discharged, the charts should be filed within the medical notes.
  • Make sure that there is clear evidence (logical rationale) for any decision you record. For instance, denying the patient access to a visitation by a family member
  • Write down your nursing notes soon after the event has occurred (this should be within 24 hours, clearly stating any subsequent additions or alterations;
  • If you have objections about the care given to the patient, be sure to document it;
  • Do not include meaningless phrases (for instance “ate well”, offensive subjective statements, inappropriate speculation and jargon in your contemporaneous notes;
  • Where possible, involve the patient or his/her caregiver when writing your nursing notes;
  • Record any plans and arrangements made for the discharge of the patient. For example, whether the patient understands the details of any follow-up appointments or whether he or she understands how to take the recommended medications.

Where to Keep Nursing Records

The nursing records should be kept where they can be easily accessed. For example, the records can be kept where the nurses meet during shifts. This way, the records will be readily available during handover sessions. After the patient has been discharged, the nursing records should be filed within the patient’s medical notes folder. If the records is stored somewhere else, make sure that the entire nursing team is aware of this.

Another important thing you should bear in mind is that patient’s data must be safeguarded. Nurses should always remember who can access patient’s records and must get consent from patients before sharing data. Good nursing note taking enhances patient care, providing a clear record of both care planned and care given. This helps nurses to provide the highest quality of care for their patients.

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