The Nursing and Midwifery Council (NMC) Code of Conduct states that we all must “keep clear and accurate records”.
Documentation and record-keeping featuring is a prominent feature in within the NMC Code of Conduct. It is your duty as a nurse or midwife to keep your notes up to date, not only to protect your patients, but also to stay on the right side of the law.
Sub standard record-keeping is one of the top five reasons for nurses being removed from the NMC register. You should consider your nursing notes as evidence of the care you have provided and will act as a reminder in the even of a complaint or investigation.
The famous nursing proverb is; ‘If it’s not written down; it didn’t happen…‘
Here are a few core guidelines you should keep in mind when you write notes on any patient:
Write as you go. The NMC says you should complete all records at the time or as soon as possible. Try to avoid leaving your nursing notes to the end of the shift – write as you go. This will ensure everything you document is fresh in your mind and therefore accurate and up-to-date.
Use a systematic approach. Try to use a systematic approach to documentation; ACBDE, SBAR etc – this will help ensure your notes are both detailed and accurate. A good methods is to; describe what happened, provide your clinical/nursing assessment and finally explain what you did about the situation.
Keep it simple. Nursing notes are designed to be quickly read, so the next shift can be caught up to speed on a patient.
Try to be concise. Writing a few lines can sometimes provide more information than writing a whole page.
Summarise. Don’t duplicate. If you have already documented a full assessment in other nursing documentation you can summarise this rather than duplicating it – your just creating yourself more work.
Remain objective and try to avoid speculation. Write down only what you see, hear and do. Try to avoid speculative comments unless they are relevant to patient care such as consideration to future care.
Write down all communication. Any discussions you have had with family, doctors or other healthcare professionals should be documented in the nursing notes. You should also document the names of people involved in discussions.
Try to avoid abbreviations. Write out complete terms whenever possible. An abbreviation can mean different things in different areas. Your trust should have a pre-approved abbreviation list.
Consider the use of a scribe. Emergency events such as cardiac arrests, trauma calls or medical emergencies commonly have poor documentation. Consider appointing a member of staff to write things down as you go; times and doses of medications, medical reviews, clinical interventions etc.
Write legibly. If nobody can read your notes there isn’t much point in writing them at all.
Finally, you should ensure your documentation is clearly signed and dated. Student Nurses or un-registered staff may need to have their documentation countersigned – you should check your local trust policy.