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8 Randmaa, M., Mårtensson, G., Swenne, C. and Engström, M. (2014) SBAR improves communication and decreases incident reports due to communication errors in an anesthetic clinic: a prospective intervention study, BMJ Open, 4(1): e004268.
9 Resuscitation Council (UK). (2015) Immediate life support, London: Resuscitation Council UK.
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12 Taran, S. (2011) An examination of the factors contributing to poor communication outside the physician‐patient sphere, McGill Journal of Medicine, 13(1): 86.
8 Written Communication
Stuart Baker
University of South Wales, UK
Chapter Aim
The aim of this chapter is to support the readers in their understanding of their obligations when record‐keeping.
Learning Outcomes
By the end of this chapter, the reader will be able to:
Understand the purpose of records
Have an understanding of the professional expectations on the practitioner with regards to record‐keeping
Understand the importance of maintaining clear and accurate records
Test Yourself Multiple Choice Questions
1 Who can access a health record?The patient, healthcare professionals and the policeLawyers, allied healthcare professionals and advocatesBoth A and B
2 Which of these pieces of legislation does not relate to record‐keeping in health?The Communication in Nursing Act 2003Computer Misuse Act 1990Access to Health Records Act 1990
3 How does The Code (Nursing and Midwifery Council 2018a) relate to record‐keeping?It underpins the need for records that are ambiguous and can hide multiple meaningsIt underpins the need for clear and accurate recordsIt does not mention record‐keeping at all
4 Is it important to sign a record, and if it is, then why is it?It is not important, as everyone’s handwriting is unique to them so it is easy to see who has made the record in questionIt is essential so that it is clear who has made a recordIt is not important as the off‐duty records which staff are on duty at any time
5 Which of these abbreviations could be confused as it could commonly have more than one meaning?DOANHSTPR
Introduction
The saying ‘If it is not written it did not happen’ has been the focus of record‐keeping texts and lectures for many years. This simple statement contains many more complex truths that will be addressed throughout this chapter.
The Nursing and Midwifery Council (NMC) standards of proficiency (2018b) for nursing associates indicate that there are many aspects of communication that must be considered by the nursing associate, and this is explored within this chapter and other chapters of this text. This chapter explores the essential aspects of communication that pertain to the need to communicate both effectively and efficiently through written records and refers to the six platforms found within the Standards of Proficiency (2018b) as well as the NMC Code (2018a). This chapter explores the subject of record‐keeping from both professional and legal viewpoints. A good starting point is to consider the purpose of a written record.
The Nursing and Midwifery Council (2018b) standards of proficiency for nursing associates represent the standards of knowledge and skills that a nursing associate must meet to be registered by the NMC as a safe and effective nursing associate. The following proficiencies apply to this chapter:
1 1.10 write accurate, clear, legible records and documentation
2 1.10 clearly record digital information and data
3 1.11 provide clear verbal, digital or written information and instructions when sharing information, delegating or handing over responsibility for care
4 1.14 demonstrate the ability to keep complete, clear, accurate and timely records
5 3.18 demonstrate the ability to monitor the effectiveness of care in partnership with people, families and carers. Document progress and report outcomes
The NMC updated its Code (Nursing and Midwifery Council 2018a) to ensure that nursing associates were also equally provided for by the NMC with a set of standards to ensure the protection of the public. In this chapter, this publication will be simply referred to as The Code.
The Written Record
A written record could be used for a number of purposes (examples of what may be considered as written records are listed in Box 8.1). Perhaps, the first thing that springs to mind is to record what has happened to a patient during a shift or care episode. This record needs to be of a certain standard which will be discussed later in this chapter. It could be reviewed firstly by colleagues using this as a means of communication to fully understand the events of the day when they are talking to the patient or relatives of the patient. It could be used in the same way by an allied health professional such as an occupational therapist who is treating the patient to have a better understanding of the patient’s abilities and condition before providing treatment and care.
Box 8.1 Some Types of Record Used by the Nursing Associate
| Nursing assessment recordsNursing care plansObservation chartsFluid balance chartsRisk assessmentsMedication chartsIncident formsCommunication pages |
Patients can have access to their record by law (this will be discussed later), and this also puts a professional onus onto the nursing associate’s record‐keeping ability. Patients may want to see their records for clarification of the care that they have received or because they feel that there has been negligence; if they lack capacity according to the Mental Capacity Act (2005), they may have an advocate who can read their records so that they are in a better position to assist the multidisciplinary team to make decisions in the patients’ best interest.
Green Flag Legislation
This Act was created in 2005 to protect all adults who do not have the capacity to make decisions, either temporarily or more permanently. Capacity is decision specific and can relate to a small decision such as what colour dress to wear or a larger decision such as resuscitation in the event of death. A full description of the