Good Record Keeping Helps to Protect the Welfare of Patients - Essay Example

Good Record Keeping Helps to Protect the Welfare of Patients 2005 Introduction The importance of record keeping in patient care processis beyond discussion. According to the Guidelines to Records and Record Keeping, 'record keeping is a fundamental part of nursing and midwifery practice' (2002, p. 6). The way the medical records are being kept and saved is a reflection of a practitioner's professional level and the standards of medical care. A good professional will always make clear written evidence of his/her work in order to provide patients with continued care and maintain one's own professional knowledge and competence. Furthermore good record keeping shows the respect to a patient and the patient's needs. The poor quality and clarity of nursing records was marked by Susan Lowson, the advisor to the Health Service Ombudsman, during The NSG conference "Information and Litigation in Healthcare" (on 11th June 2003) at Kettering General Hospital Post Graduate Medical Centre. Therefore there is a little work to be done in the field of record quality improvement. The detailed description of a patient's case history, condition and treatment help the members of the inter-professional health care team to communicate and cooperate. This may help when the patient receives the treatment from different specialists and the important information, such as blood group, allergic reactions, specific noncompatible prescribed medicines etc. should be reported to every doctor. The records are vital in doctor-nurse cooperation as they help a nurse to follow the doctor's prescriptions and a doctor to control the smallest changes in the patient's condition without keeping him under close observation as in case of long, or life-long disease when the patient receives regular nurse care and one-day-per-month doctor's examination. Good record should be written in a clear and accurate way (intended for a particular type of the record) to present the accurate account of treatment and care planning and delivery, and the record keeper should therefore follow special rules and recommendations of the authoritative organisations. Clear and consecutive records of a patient's condition help to detect problems rather than scrappy, incomplete, and inconsequent notes. Rigorous, detailed description of case history, the changes in patient's condition, medical conclusions, recommendations, and prescriptions help not only provide the successful treatment but also to protect the rights of a doctor or a patient in case of litigation. Thus a high level of record keeping provides patients' welfare. Good medical record keeping helps to provide continuity of care Continuity of care is an important component of medical service. Continuity is not an attribute of providers or organisations, it is rather the way individual patients experience integration of services and coordination. Therefore continuity of care is a significant characteristic of medical care level. According to Guidelines for Record-keeping (2005, p.7), the Audit Commission (1995) found patients were suffering as a result of poor communication between professionals, even within the same area of practice and/or ward/base. The reason for that was that records were frequently treated as the personal property of a practitioner instead of as a corporate asset to promote quality care. The Trust is committed to promoting integrated patient records to support safe and effective care. It is strongly recommended, that where possible, practitioners should use or develop records that other professionals and the patient/carer/relatives are able to use to promote continuous effective care for the patient. An example of how and where this system of integrated record keeping works are the personal child health records. All practitioners should use this shared record during any interventions with a child who was given one (normally by their health visitor) at the time of their birth (after circa 1994). According to the research conducted by the international group of medical experts, informational continuity is one of three types of continuity: Informational continuity-Information is the common thread linking care from one provider to another and from one healthcare event to another. Information can be disease or person focused. Documented information tends to focus on the medical condition, but knowledge about the patient's preferences, values, and context is equally important for bridging separate care events and ensuring that services are responsive to needs. This type of knowledge is usually accumulated in the memory of providers who interact with the patient (Haggerty, J. L., Reid J., R., Freeman K, G., Starfield, H., B., Adair, E., C. & McKendry, R. 2003). Good record is the primary source of information for different members of health care team and therefore is the important tool of informational continuity of care. In the Code of Professional Conduct it is also notified that health care record is a tool of communication within the team (2002, p.6). There are special requirements the record should satisfy to fulfil the task of good and reliable informational source. If the information from the Code of Professional Conduct (2002, p.6), and the medical experts recommendations (Haggerty, J. L., Reid J., R., Freeman K, G., Starfield, H., B., Adair, E., C. & McKendry, R. 2003) is summarised and evaluated, the following standards can be set for the medical records: The record should be focused both on the medical condition and the patient's preferences, values, and context; The record should be written with the involvement of the patient or client; The record should be made as soon as possible after the event has occurred; The record should be an accurate account of the care planned, the decisions made, the care delivered and the information shared. The records should not contain abbreviations, other than widely accepted and understandable for every member of health-care team and a patient. Ambiguity and jargon are inadmissible. Records should not contain meaningless or personal judgemental statements such as 'funny colour of face today' or 'disgusting wounds'. The one who makes records should be absolutely objective and should not give any judgements, other than professional, proved by observed evidences. The records should look like an official document but not like a private diary or a letter to the old friend. Thus continuity of care is an essential part of health care process and patient's welfare. The records play the key role in keeping the necessary medical information and in supplying every member of health-care team with this information. Only detailed, rigours, informative and consistent records can provide the patient with qualitative medical service during continuity of care. Confidentiality in record keeping Confidentiality of patient information and particularly records is not only the measure of respect to the patient but also an ethical and legal duty of every medical care provider. Confidentiality is one of the highest standards of medical care. The duty of confidentiality for nurses and midwives is established in Code of Professional Conduct (2002): 5. As a registered nurse, midwife or health visitor, you must protect confidential information. 5.1 You must treat information about patients and clients as confidential and use it only for the purposes for which it was given. As it is impractical to obtain consent every time you need to share information with others, you should ensure that patients and clients understand that some information may be made available to other members of the team involved in the delivery of care. You must guard against breaches of confidentiality by protecting information from improper disclosure at all times. 5.2 You should seek patients' and clients' wishes regarding the sharing of information with their family and others. When a patient or client is considered incapable of giving permission, you should consult relevant colleagues. 5.3 If you are required to disclose information outside the team that will have personal consequences for patients or clients, you must obtain their consent. If the patient or client withholds consent, or if consent cannot be obtained for whatever reason, disclosures may be made only where: they can be justified in the public interest (usually where disclosure is essential to protect the patient or client or someone else from the risk of significant harm) they are required by law or by order of a court. Where there is an issue of child protection, you must act at all times in accordance with national and local policies. Obviously, the concern about confidentiality is closely related to protect the patient, his/her feelings and emotional comfort. The main argument against sharing the confidential information is the patient's welfare. There are several legal documents, acts and guidelines that set out the medical records confidentiality and regulate the access to them. The Human's Rights act 1998 sets out the right to a private and family life, and it is possible that this may be used to challenge the present regime on confidentiality of patient. Core Standard 3 (CSP, 2000) sets out the requirements for physiotherapy records. This advice is in keeping with, and complementary to, the Rules of Professional Conduct, particularly Rules III (CSPc, 1996). Arrangements should be in place for the safe storage and retrieval of all records. This may be the responsibility of the medical records or the physiotherapy department/clinic/practice (General Principles of Record Keeping and Access to Health Records 2000). Access to patient records According to The Access to Health Record's Act 1990, patients and clients have the right of access to manual health records about themselves that were made after 1 November 1991. The Data Protection Act 1984, which sets the rules for processing personal information and applies to paper records as well as those held on computers, gives patients and clients access to their computer-held records. It also regulates the storage and protection of patients and clients information held on computer. The system for dealing with applications for access is explained in the Guide to the Access to Health Records Act 1990, which is published by the government health departments. A large variety of documents regulate legally the keeping and access to medical records, and there is a plenty of details that are being regulated. A short summary of British Medical Association (BMA 2002) can help to classify the key points. The summary is based on Data Protection Act 1998, The Access to Health Records Act 1990, The Access to Health Records (Northern Ireland) Order 1993, and on implementation of data protection legislation in early 2000, which 'changed patients' statutory rights of access to their health records' (BMA 2002). This summary covers all manual and computerised health records about living people are accessible under the Data Protection Act 1998. Access must be given equally to all records regardless of when they were made all over the UK. Competent patients, or their parents (if a patient is a child and application is in the child's best interest and not on contrary to a competent child's wishes) may apply for access to their own records, or an authoritative third party on their behalf. People appointed by a court to manage the affairs of mentally incapacitated adults may have access to information necessary to fulfil their function. Competent young patients can also seek access to their own health records. Patients have a right to be informed whether personal data about them is being processed and they have a right to get all the information about this procedure. Here can be added that all practitioners are individually responsible for informing clients of any records created for them, the reasons they are kept and of any public health related data collected for the purposes of community profiling and health needs assessment, even if anonymous (Guidelines for Record-keeping 2005, p.5). The information cannot be disclosed if it is likely to cause serious physical or mental harm to the patient or another person. The decision about likely harm must be taken by the appropriate health professional, usually the treating doctor. Circumstances in which information may be withheld on these grounds of harm are extremely rare. The information cannot be disclosed also if it relates to a third party who has not given consent for disclosure (where that third party is not a health professional who has cared for the patient). However, in some cases doctors can still disclose the information in the records without revealing the identity of the third party. This might be done by omitting names and identifying particulars from the records before disclosure, and care should be taken to ensure that the information is genuinely anonymous. If patients express views about future disclosure to third parties, this should be documented in the records. Patients are entitled to a copy of their records. It is not necessary for a patient to make a formal application for access to see their records. Formal applications for access, if there are any, must be in writing and accompanied by the appropriate fee. The fee is charged for providing access and copies of the records (10-50). The Secretary of State prescribes the maximum fees, which may be charged. No fee may be charged for allowing patients to read their records if all the information requested is held in manual form, no copy is requested, and at least some of the record was made in the 40 days prior to the request. If a person has a claim arising from the death of an individual, he or she has a right of access to information in the deceased's records if necessary to fulfil that claim. The provisions and fees in these cases are slightly different from those in the Data Protection Act 1998. Requests for access are made to the person in charge of keeping the records; the data controller. This is usually the health professional responsible for the patient's care, but may in some circumstances be another health professional or, for example, a member of records management staff. The courts have the power to order disclosure or non-disclosure. Patients or other people likely to be affected by disclosure (for example a person likely to suffer serious harm if information is disclosed) can apply to the courts. Inter-professional access to records As it was already discussed above, the cooperation of all the members of health-care team is very important for the patient welfare, and the sharing of the records is one of the ways of this cooperation. NMC supports the idea of shared records, where all the members of health-care team, involved in the care and treatment of an individual can make entries of an equal importance in a single record and in accordance with an agreed local protocol (Guidelines for Records and Record Keeping 2002). The same guidelines set that patient and client records may be used for research, teaching purposes and clinical supervision. The principles of access and confidentiality remain the same and the right of the patient or client to refuse access to their records should be respected. As it can be seen, the rights of access to private medical records are based on the respect to patient confidential information and cannot be obtained if a patient is likely to be harmed by disclosure. The exceptions are rare and are usually made only when data are necessary for a court of law. The Question of Litigation Any organisation or profession cannot avoid the mistakes. In the same way health practitioners occur to err. If a medical treatment failed to provide the patient's recovering, if the professional mistake took place and had as a result deterioration of the patient's condition or death, the doctor carries legal responsibility for his/her failure. Medical records are the main evidence that can prove the doctor's fault. The fact that medical records may be the evidence in a court, is discussed in many documents and guidelines: Investigations into complaints about care will look at and use the patient/client documents and records as evidence; so high quality record keeping is essential. The hospital or care home, the NMC, a court of law or the Health Service Commissioner may investigate the complaint, so it makes sense to get the records right. A court of law will tend to assume that if care has not been recorded then it has not been given Medical records may also be used in evidence by the NMC's Professional Conduct Committee, which considers complaints about professional misconduct by registered nurses and midwives" (Nursing documentation, record keeping and written communication 2004, p. 2). "Record keeping is a professional requirement of all physiotherapy practice and requires specific skills. Failure to maintain a physiotherapy record would cause considerable difficulties in respect of any legal proceedings, e.g. allegations of negligence" (General Principles of Record Keeping and Access to Health Records 2000, p.2). All health records are subject to the law regardless of whether they are hand-written or computerised and where they are held (Guidelines for Record-keeping 2005). Opposite situation is also possible, when the patient didn't follow the doctor's prescriptions or a pharmacist sold the wrong medicine. For instance, during a poster session at the 2nd meeting organised by the EFAHP to promote safe, effective and economic patient care in Europe, the London Region NHS, Clinical Pharmacy Service reported that 684 incidents of wrong medicine-use were recorded at nine trusts in a five-day period during March 2002, mainly relating to 'near-misses' or medicine errors that have been picked up by pharmacy stuff before the patients was affected (Evans 2000). If these errors have had harmed the patients, 684 litigations would have been occurred. In any of these situations the record keeping can identify whose fault caused the patient's harm. In order to be sufficient lawful evidence, medical records need to satisfy some requirements. The summarised information from the Nursing documentation, record keeping and written communication, Guidelines for records and record keeping, Guidelines for Record-keeping is given bellow: - The records should be rigorous, detailed, consistent and regular with the frequency of entries determined by the local standards and agreements and one's own professional judgement. Record keeping should be able to demonstrate a full account of doctor's or nurses assessment and the care that have been planned and provided. Relevant information about the condition of the patient or client at any given time and the measures that have been taken. Any arrangements that have been made for the continuing care of a patient or client should be recorded. Nursing documentation, record keeping and written communication advises to use mnemonics in order not to forget the details of an entry - RACPIAN: Reason (for visit/contact/admission); Assessment (of situation); Concerns (diagnosis or problems identified); Information (relevant); Plan (of action); Action (carried out); Next contact/follow-up; Any entry made in a record should be easily identified and signed clearly, preferable with the name printed near the sign. It is strongly advised not to use the initials only as a signature. The date and sign of the entry are very important, as inaccuracies about events (dates and times do not tally etc.) are the most common mistakes of record keeping (Clarke 1999). The records should be made in black ink; no coloured ink is permitted in order to make it possible to copy the documents; Some specialists need to use special guidelines for their records such as Midwives rules and code of practice that relate to the maintenance and retention of records or Mental Health Act Commission for England and Wales, the Mental Welfare Commission for Scotland or the Mental Health Commission for Northern Ireland for mental health care nurses. Useful recommendations to nurses about how to avoid the litigation are given in the article by Anne Bevan (2004), Solicitor specialising in Health Law. First of all she notifies: "The most obvious way to protect yourself is to always make full and accurate notes". And what is more important: "If you have provided wonderful care but recorded nothing in the notes, it is extremely difficult to defend any alleged shortcomings". Ms Bevan strongly recommends the nurses to record exactly the time a doctor was called and at what time he arrived, because there are often conflicts centred on nurses failing to summon help at an appropriate time and this information in the nursing notes may clarify issues. Consequently health record is the evidence for a lawful process and therefore should be written in the way to make it possible to use it in a court. Following this recommendation, a health care practitioner demonstrates the care he/she provides, hence can easily prove his/her actions and competence should the litigation happen. When it comes about patient's welfare in this context, a patient can always be sure that no medical error will stay unproved and this thought surely helps him/her to feel safe and comfortable. General types of nursing documents Basic requirements for medical records were discussed above. There are, however, special requirements to some particular types of nursing documents, which are usually used in hospitals and clinics. The importance of these documents for patient welfare (during the processes of medical care and litigation) is the same as of the causal medical records (diaries). The different types of nursing documents are described in the Nursing documentation, record keeping and written communication (2005). Nursing assessment sheet The nursing assessment sheet contains the patient's biographical details, the reason for admission, the nursing needs and problems identified for the care plan, medication, allergies and medical history. Nursing care plan The documents of the care plan will have space for: - Patient/client needs and problems; - Sometimes, nursing diagnoses will be documented; Planning to set care priorities and goals. Goal setting should follow the SMART system, i.e. the goal will be specific, measurable, achievable and realistic, and time-oriented; - The care/nursing interventions needed to achieve the goals; - An evaluation of progress and the review date. This might include evaluation notes, continuation sheets and discharge plans; - Reassessing patient/client needs and changing the care plan as needed. Vital signs The basic chart is used to record temperature, pulse, respiration and possibly blood pressure. Basic charts may also have space to record urinalysis, weight, bowel action and the 24-hour totals for fluid intake and output. More complex charts, such as neurological observation charts, are used for recording vital signs plus other specific observations, which include the Glasgow Coma Scale score for level of consciousness, pupil size and reaction to light, and limb movement. Fluid balance chart It is used to record all fluid intake and fluid out-put over a 24-hour period. Fluid intake includes oral, naso-gastric, via a gastrostomy feeding tube, and infusions given intra-venously, subcutaneously and rectally. Fluid output from urine, vomit, aspirate from a nasogastric tube, diarrhoea, fluid from a stoma or wound drain are all recorded. Medicine/drug chart A basic medication record will contain the patient's biographical information, weight, history of allergies and previous adverse drug reactions. There will be separate areas on the chart for different types of drug orders. These include: - Drugs to be given once only at a specified time, such as a sedative before an invasive procedure; - Drugs to be given immediately as a single dose and only once, such as adrenalin (epinephrine) in an emergency; - Drugs to be given when required, such as laxatives or analgesics; - Drugs given regularly, such as a 7-day course of an antibiotic or a drug taken for longer periods (e.g. a diuretic or a drug to prevent seizures). All drugs, except a very few, are ordered using the British Approved Name, and the order (or prescription) will include the dose, route, frequency (with times), start date and sometimes a finish date. There is space for the signature of the nurse giving the drug and, in some cases, the witness. It is vital to record the time a drug was given. This is done at the time so that all staff know that it has been given, and do not repeat the dose. Likewise, if the drug was not given for some reason, this fact should be recorded on the medicine/drug chart and the doctor is informed if necessary. Incident/accident form Any non-routine incident or accident involving a patient/client, relative, visitor or member of staff must be recorded by the nurse who witnesses the incident or finds the patient/client after the incident happened. Incidents include falls, drug errors, a visitor fainting or a patient attacking a member of staff in any way. An incident/accident form should be completed as soon as possible after the event. Conclusion As was discussed above, good record keeping helps to protect the welfare of patients. The records should pass the standards set by authoritative organisations, for example NMC. The records, kept in the framework of these standards, are clear, accurate, informative, consistent, properly signed and dated, and are therefore an official document. This style of records helps to provide the continuity of care, effective cooperation between the members of health-care team, and helps to keep the patient under rigorous medical observation. The whole purpose of writing and keeping medical record is to document important information about the patient and his/her health condition in order to use this data for the welfare of patient. The record can be used in no other purpose, unless this purpose is obtained by court. Every health care practitioner should therefore remember about the object of the record and keep the record in the interests of the patient. References Access to Health Records Act 1990. Bevan, A., 2004, The nurse and the law-4-Hot tips to avoiding litigation, Available at: http:// www.n2nmagazine.co.uk/articleDetails.aspArticleID=261 British Computer Society Nursing Specialist Group (BCS), 2003, Information and Litigation in Healthcare, Available at: http://www.bcsnsg.org.uk/conf03 Clarke A. 1999. Community Nurses and the Law.: CPHVA, London. Curtis, T., Holland S. (eds), 2005, Guidelines for Record-keeping (All practitioners), Available at: http://www.berkshire.nhs.uk/.../documents/clinical_policies/ record_keeping_guidelines_practitioners_as_at_jan05.pdf Data Protection Act 1984. Department of Health (DH), 2003, Confidentiality: NHS Code of Practice, Available at: http://www.doh.gov.uk/ipu/confiden Evans, D. 2002, 'New initiatives to help in prevention of medication errors', The Pharmaceutical Journal, vol. 296, pp. 76-77. Haggerty, J. L., Reid J., R., Freeman K, G., Starfield, H., B., Adair, E., C. & McKendry, R. 2003, Continuity of care: a multidisciplinary review, Available at: http://bmj.bmjjornals.com/cgi/content/full/327/7425 Nursing and Midwifery Council (NMC) 2002, Code of professional conduct, Available at: http:/www.nmc-uk.org/nmc/main/publications/codeOfProfessionalConduct.pdf Nursing and Midwifery Council (NMC), 2002, Guidelines for Records and Record Keeping: Protecting the Public through Professional Standards, Available at: http/www.nmc- uk.org/nmc/main/publications/GuidelinesForRecordsAndRecordKeeping.pdf Parkinson And Brooker: Everyday English For International Nurses, 2005, Nursing documentation, record keeping and written communication, Available at: http/www.intl.elsevierhealth.com/e-books/pdf/914.pdf The British Medical Association (BMA), 2002, Access to health records by patients, Available at: http://www.bma.org.uk/ap.nsf/Content/accesshealthrecords The Chartered Society Of Physiotherapy (CSP), 2000, General Principles of Record Keeping and Access to Health Records, Available at: http:/www.csp.org.uk The Human's Rights Act 1998. 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