The police may request access to a patient’s notes in certain circumstances, and they may use a court order to do so. The person in charge of the patient’s care is known as the ‘data controller’ and may share the records informally without the order being sought. Certainly, this applies where the access is in the public interest such as when a patient has a communicable disease and the public health department requires the police’s assistance in finding a patient and preventing the transmission of the disease.
Finally, a solicitor or legal professional may request access to records. The records that they may request may be the medical records only, but they may also want to examine nursing records as well. Potentially, therefore, nursing records could be used in court of law.
Touch Point
There are a number of organisations and individuals that can access nursing and medical records. As nursing associates, it is necessary to ensure that all records that are made are in a format that can be followed and understood by others. The remainder of this chapter is dedicated to making record‐keeping clear and compliant with policies and procedures.
Now that it has been established that a variety of people may access records for an equally varied number of reasons, the remainder of this chapter has been divided into two sections. First, the professional requirements from the NMC will be discussed in depth. The second part of this chapter includes a brief discussion on some legislative background to record‐keeping.
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Always use factual, reliable, accurate, objective and unambiguous patient information.
Employ your senses in order to record what you did, for example, ‘I heard’, ‘felt’ and ‘saw’.
Where necessary, use quotation marks when you are recording what has been said to you.
Be sure there is evidence provided for any decision recorded, for example, denying access to a visit from parents.
Notes must be accurately dated, timed and signed, with your name printed alongside the entry, and avoid the use of initials.
Make a note of any objections you may have to the care that has been given.
Do not include jargon, meaningless phrases, such as ‘patient had a good day’, irrelevant speculation and offensive subjective statements.
When writing notes, where this is possible, do so with the involvement and understanding of the patient or carer.
Professional Requirements
When considering record‐keeping, it is important to start with the Nursing and Midwifery Council’s (2018a) standards of proficiency for nursing associates that concludes that all nursing associates must keep clear and accurate records which are relevant to their practice, but while there is no specific professional document on keeping records, nursing associates must refer to The Code for guidance. Section 10 states that all nursing associates are to ‘keep clear and accurate records that are relevant to your practice’. The Code reminds the nursing associate that this applies to all records that are kept as part of the nursing associate’s role and is not limited to just patients’ records. The Code then lists a number of practical actions in subsections of Section 10.
The first subsection clarifies that every record must be made in a timely manner and as soon after the event as possible. This reminds the nursing associate that, as often as possible, records must be made at the time an event happens or as soon after it happens as possible. This is for several reasons but primarily as a record made while the sequence of events is fresh in the mind is probably going to be a more accurate record than one that is made later. This is just the same for a patient record as for an accident form or any other record. The second reason for making a timely record is a reminder that all records are made to improve patient safety. A record made in good time will help to prevent duplication of an episode of care. For example, if an action has been taken based on an old record rather than the latest episode of care, the patient could have the same drug administered twice or have the same referral made twice.
The next practical action listed in Section 10 is that the written record maintained by the nursing associate must ensure that all risks that have been identified or problems have been recorded along with the steps that have been taken to remedy these risks and problems. This action helps to ensure that other healthcare professionals who use the records have all the information that they need. One example of this is if the nursing associate identified that a patient was finding it difficult to mobilise with a walking stick, this would be recorded along with the fact that the patient had been referred to the physiotherapist. When the physiotherapist visits the patient, they can see clearly from the record what the problems were and why the referral had been made. Another application here that has to be considered is that if a patient was to make a claim of negligence regarding their care. The record relating to their care must clearly show that the nursing associate had identified the patient’s care need and reported it to the registered nurse in charge before recording this in the nursing notes. This would then demonstrate that a risk had been identified and appropriate steps had been taken to alleviate this risk.
The third practical action requires that all records must be completed accurately and without any falsification. It is not realistic to maintain records without ever making a mistake either by misspelling a word or by using a word that you did not mean to use in that context. Therefore, it will be necessary to mark a mistake or delete a word within a written record. This must be done by scoring through the mistake with a single line rather than obliterating the mistake with scribbles or correction fluid (liquid paper).
Take Note
Supporting Evidence
In the rare case of needing to alter a record, the original entry must remain visible (draw a single line through the record), and the new entry must be signed, timed and dated (RCN 2015).
It is essential that all nursing associates do not falsify records either by recording that something has occurred when it has not or by falsifying or forging a signature attributing a record to another person for whatever reason. You may come across a record made by another healthcare professional that has not been signed by them. In a situation like this, do not consider putting their signature adjacent to the record; the two choices which could be followed are:
1 Alert the individual as soon as possible so that they can add the necessary signature to the record or
2 Where there is going to be a considerable gap in time before this signature can be entered, a senior nurse on the ward (or care area) must be advised, and appropriate action can be taken.
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