The Nursing Associate's Handbook of Clinical Skills. Группа авторов

Myers is caring for a patient named Renuka in her own home. She had been off duty for three days; she looks at Renuka’s care plan and the documentation written by staff nurse Willis who had been caring for her over the previous three days and notices that the staff nurse has forgotten to sign the various entries she has made in Renuka’s nursing notes, in fact all of them. Lilly calls staff nurse Willis who is office based and explains the situation to her. Staff nurse Willis requests, ‘please can you sign the entries for me and when I get back off leave in two weeks I will counter sign’. Lilly refuses, and staff nurse Willis says in a rather harsh tone, ‘that is the last time I do you any favours, any way I am on leave now’. How do you think Lilly should proceed?

      When the nursing associate is undertaking a programme of education leading to registration and is completing clinical learning outcomes during a clinical placement, it is important that only the allocated mentor or practice supervisor signs off the clinical learning outcomes as they are completed. The situation may arise where the student and the mentor discuss a clinical learning outcome, but then, the mentor forgets to sign. This is a form of record, as indicated by the NMC, which does not directly relate to patient care; however, this record does enable the student to progress to registration and then directly affect patient care. Therefore, it is essential that the student does not falsify this signature in this situation but requests the mentor to complete the record at their next meeting.

Section 10 requires that each nursing associate attribute any entry that they make in any paper or electronic records to themselves, in essence they own that entry. This is linked to the previous practical action very closely. If the record is paper based, then it is essential that the signature (or initials on certain records) is clearly identifiable and consistent. In many clinical areas, a register will need to be completed which allows the nursing associates to first clearly write their name and then adjacent to this enter a specimen of both their signature and their initials (see Figure 8.1).

      This is a particularly useful approach to accountable record‐keeping when looking at records historically and examining records that have been made by agency or bank staff that may have only made a limited number of entries and indeed their signatures alone are not familiar.

      If the record is made electronically, then it is essential that it be ‘signed’ by the correct author. This will require healthcare professionals to log off a computer and then log in with their own identity before making an entry; otherwise, the entry will be attributed to the healthcare professionals who have already logged into that recording device. While this signature or identity may not be seen by the individual making the entry, the computer system will record who was logged in as the person making the entry. This reinforces the importance of logging off from any device after a record has been made and also that the login details are not shared with another nurse or nursing associate so that any record subsequently made is attributed directly to the nursing associate who is identified as being logged on to the recording device.

Figure 8.1 An example of a specimen register used in a general practice.

One of the final subsections within Section 10 requires the nursing associate to make sure that all records are clearly written, dated and timed, and that they do not include unnecessary abbreviations, jargon or speculation. As this subsection contains detailed guidance for record‐keeping, this will be now discussed in several sections. These requirements of the NMC Code are also echoed by the NMC proficiency standards (2018) that state that records are to be written accurately, clearly and legibly. Accuracy and clarity are quite inseparable. The nursing associates must also remember that there will be quality standards in their workplace that will govern how they are required to undertake documentation; they must not deviate from these standards.

      Touch Point

      Think about a record that you have written. Was this record both accurate and clear? How could this be improved?

Legible and Clearly Written

      These are two terms used by the NMC which possibly have similar meaning, although clearly written could be interpreted as more than just legibility. To reiterate, the nursing associate must ensure that all records are made in such a way that they can be read by another healthcare and social care professional. Legibility is therefore very important to ensure that all records made communicate necessary information about the patient for whom the record has been made. As discussed previously, when looking at who has access to records, it was seen that a number of professionals, including the legal community, police as well as healthcare and social care professionals can also access records, and as such, content must not be ambiguous or difficult to read or decipher. Legibility requires that when a record is made by hand, black indelible ink is used, and pencil must not be used as this can be erased and rewritten at any time. Furthermore, many pencil leads fade with time; therefore, this does not make a permanent record. Often, local policy requires all record makers use black ink as this can be more permanent and photocopies and scans better than blue ink. If in doubt as to what a local policy is on record‐keeping, then using black ink is always a safe default position; you must seek advice if you are unsure. Legibility is also concerned with the alteration of a record in a clear way. A record that has been clearly written will also consider other issues such as language.

Language

The language used in records must be unambiguous in its meaning. This requires that it is factual and not open to interpretation in any way which could lead to confusion and ultimately could result in a patient not receiving the care they need or care that may cause them harm. If a patient, for example, has had their vital signs measured and recorded every 15 minutes, then this frequency must be recorded rather than a simple entry to state that the patient’s vital signs have been measured. The fact that the reader now knows that the vital signs have been recorded every 15 minutes conveys a message that the patient’s needs are such that they require close monitoring.

      Yellow Flag

       When making an entry in a record or documenting care outcomes, the nursing associates must ensure that entry that they are making in the record is factually correct. Only record what you, as the nursing associate, see, hear or do. Using emotive statements can hinder the nursing associate and other readers of records from making objective decisions regarding the patients and their care.

      Another example would be if a patient is incontinent of urine and faeces, the written record should be identifying this rather than simply stating that the patient has been incontinent as this again does not fully and accurately convey or report on the needs of that patient. This would also have implications for future reviews to be completed; they may not be accurate as the information about the type of incontinence is not available to the next person undertaking a review. The subsequent reviews are also recorded, and as such, the principles of accuracy and clarity will also apply.

      Red Flag

       When the nursing associate fails to document care provision in the correct manner, this can result in serious harm to a patient’s health and well‐being. These failures are attributable to human errors. Harm can occur when there is a wrong or delayed response to care, and this can be a result of failure to capture documented signs and symptoms and laboratory tests and failure to undertake, document and report care findings. Poor documentation, failure to read and understand a patient’s nursing and medical record, can put a patient at serious risk of harm.

      Reducing the