Jargon and Abbreviations
Language that is used in record‐keeping must also be jargon free. It is worth remembering that the language used in the record could be interpreted or misinterpreted by any of the previously mentioned groups, including families, patients, allied health professionals and external agencies such as the police. There are abbreviations that are commonly used in all walks of life such as National Health Service (NHS) which most people would know refers to the NHS; however, there are many times when jargon or abbreviations should not be used, for example, MI which could stand for myocardial infarction but could equally stand for motivational interview or DOD which could mean date of discharge or date of death.
This does not mean that medical terminology and abbreviations should not be used such as cerebrovascular accident (CVA) as opposed to writing stroke (note the convention of writing the term in full and then abbreviating the term afterwards. This gives clarity as to abbreviations and their meaning later in the record.) In this instance, it is the lay term stroke that has several meanings, whereas CVA is quite explicit.
Due to instances where a word used in a record has had different connotations and the appropriate or required action has subsequently not been forthcoming, the requirement for records to be made clear by being jargon free is apparent. Linked to this section, there has to be a consideration of spelling.
Spelling
Many computer programmes used for record‐keeping contain spell checkers, although these should not be relied upon as when words are not spelt correctly but the misspelled word is still a word, the spell checker would overlook this. For example, if the word ‘loose’ was mistyped as ‘lose’, this would have a different meaning, but as it may be a proper word, the mistake would be undetected by the computer. This highlights the importance of proofreading the entries, as other healthcare and social care professionals reading this record would assume that the patient had lost their bowels completely rather than having diarrhoea which is the intended message.
In written records, there are no spell checkers that can be used. Few nursing associates or registered nurses would be able to ever say that they had never made a spelling mistake or typing error within a record; how these are managed and minimised can improve the accuracy and clarity of the record. In some instances where perhaps a drug name is being recorded or a diagnosis is being written, it is essential that the word is spelt correctly. In these instances, it is a good practice to use a good nursing or medical dictionary. Many of these dictionaries are available online and are easily accessible through apps on mobile devices. The earlier guidance regarding making corrections is important so that the reader can see that the misspelled word has been changed and that the crossed‐out word was nothing more than a correction and not an attempt to alter or falsify a record. While discussing clarity of a record, it has to be considered that a record should be timed and not just dated to demonstrate that care has been provided and there is sequential logic to the entry.
Supporting Evidence
The Royal College of Nursing (2010) has produced some good suggestions in a tool kit, for nursing associates and other healthcare professionals with dyslexia, dyspraxia and dyscalculia.
Dated and Timed
The NMC requires that all records be dated and timed, and all records must be made in a timely fashion as soon as the event as is reasonably possible, and The Code emphasises this. All computer records will be automatically dated and time‐stamped when the record is made; however, the computer will not recognise that a record may relate to an event that occurred two hours ago and the time attributed to the record will be the current time. Therefore, it is imperative that all nursing associates attribute the correct time. The same can occur during the night where a record is made after midnight relating to an episode of care that occurred before midnight. In this instance, the date as well as the time needs to be correctly identified. This applies equally in a written record, but the written record will make no automatic assumption or entry in relation to the date and time, and the nursing associate must make this a clear part of any record that they make. The timing of a record demonstrates the sequence of care events. Ideally, records are made at the time of the event and, therefore, will be in the correct chronological order; however, when this is not possible, it is a good practice to indicate the time that the record relates to so that anyone examining the records historically (in retrospect) can establish a time line of events. The format of the time must be considered; the 24‐hour clock is much harder to confuse in a record that uses the 12‐hour clock. For example, in the 12‐hour clock, 1 o’clock appears twice, whereas in the 24‐hour clock, these are clearly written as 01:00 h and 13:00 h. Recording 1 a.m. and 1 p.m. can be confusing, and the differentiation in the 24‐hour clock is very clear. The final NMC element of The Code with regards to record‐keeping is the issue of speculation.
Speculation
The subject of speculation in records made by nursing associates is an important requirement when considering clarity. Not making any speculation in record‐keeping requires accuracy, and there must be no guessing, for example, recording that a person with a high temperature may be septic when the diagnosis has not been confirmed by a senior nurse or doctor demonstrates speculation. All records must be factual in nature.
Touch Point
How could these five records be documented so that they are not speculative?
| Mrs Jones has a high temperature | |
| Mr Thomas has passed a large amount of urine this afternoon | |
| Mrs Kowalczyk’s blood glucose is high, and she will probably have a stroke | |
| Mrs Evans has diarrhoea; she must have eaten something bad | |
| I think Mr Morgan is in pain |
Speculation could also be interpreted as an attempt to gamble. Putting this into the context of record‐keeping, it would mean drawing conclusions with only part of the evidence; here, the nursing associate speculated and fails to consider facts. Gambling could mean that there is a 50% chance that the conclusion drawn is correct. This means that there is also a 50% chance that the conclusion drawn is incorrect; therefore, all records must be maintained factually and not speculatively. Similarly, speculation could mean ‘to assume’. Just because a person appears a certain way, an assumption must not be drawn. Again, records must deal in facts only. The next requirement of the NMC Code that relates directly to record‐keeping discusses secure storage.
Safe Storage
Section 10.5 of The Code states that all nursing associates must take all steps to make sure that records are kept securely. Whether a record is made and stored electronically or by hand, the requirement and expectation regarding storage is the same. Firstly, computerised records will generally be stored securely, and the backup of such documents will be automated by an IT department so that the final security and integrity of a record is maintained on the whole without the nursing associate having to be concerned with safe storage of the record. Safe storage also concerns access to records, and the nursing associate is accountable and responsible for any actions or omissions. With regards to safe storage, many computers have a lock screen which automatically engages after a set period of time that the computer is idle. This set time varies from computer to computer but could be as little as a couple of minutes to 15 minutes.