Time and time again, nurses and para medical staff are constantly criticized and scrutinized for not practicing good record keeping practices.
Good record keeping skills are an absolute must in the healthcare department. With the recent legal implications and new ordinances, nurses are now expected to vigilantly document every single thing on paper that they administered to the patient, in order to safeguard themselves from any unforeseen situation.
In the view of this practice, the NMC 2002c has clearly stated that a nurse should write down relevant information about patients’ condition, a relevant account of the nurse’s assessment and steps he/she took to improve the condition of the patient along with any other arrangement they might have made for the patient.
Apart from documenting the medical condition of the patient just for the sake of documentation, legal processions and litigations are also a tough reality to remember. With hefty patient load, it is almost impossible for a nurse to remember a certain patient’s history and treatment methods years later during court trial. To avoid such a bitter situation, it is always advised to improve the way you document patient records, write them in a relevant and professional way in order for them to comprehensible.
Other than legal implications, a good record keeping of the patients’ condition and steps to ensure patient care are always vital to handover to the nurse and doctor coming in the next shift. According to NMC guidelines, a patient’s record should be of such professional standard, that even if the nurse decides to not turn in to work the next day, patient care and health shouldn’t be compromised, orders and commands be written in a clear way and easy to understand and implement.
Nurses can also use DICOM server software for DICOM files and related data.
Most of the hospitals have DICOM receiver software or similar tools, which only take some training to master.
Here are some of the ways nurses can improve their record keeping skills:
- While writing down the patients’ health record, always use factual, consistent, to the point language, and relevant information.
- When documenting a certain finding, use words such as ‘I heard’, ‘I saw’ to further confirm the finding.
- Use of appropriate grammar and quotation marks is encouraged wherever necessary. Always try to quote anything that the patient has said to you in their own words.
- Make sure you document a reason for any decision you took on part of the patient, such as denying frequent visits from family.
- Make sure your patient record notes are accurately dated, signed and timed to avoid any such hassles. This is the most basic yet most important aspect of record keeping to be aware of.
- Your notes should have all the details relevant to the patient, with no jargon or difficult phrases.
- In the midst of any occurring or an event related to the patient, make sure to document the incident as soon as you can, preferably within 24 hours.
Proper record keeping skills can go a long way in ensuring professionalism, better standard of care for the patient, and can prove life saving for the nurse in the event of any legal implications.