Levels 1, 2 & upwards, Clinical & Non clinical, Hospital & Community

Exercise 5

Facilitators notesThis is the largest exercise, it contains a range of activities related to record keeping and recording interactions. You may wish to select to use those of relevance/transferability to your groups area of practice.

High Quality Care for All DH 2008 identifies quality as the organising principle for all services There is a link to High Quality Care for All

The Commissioning for Quality and Innovation (CQUIN) payment framework makes a proportion of service providers’ income conditional on quality and innovation. The framework helps ensure quality is part of the commissioner-provider discussion everywhere.

http://www.institute.nhs.uk/world_class_commissioning/pct_portal/cquin.html

Many staff will be registered professionals working to professional codes of conduct, nonetheless all employees will be working within national legislation, Department of Health guidance and Trust policies. Patient safety and quality in service are paramount. High standards in record keeping are as much a part of that quality in service as the actual service provided. The standard of record keeping is a reflection of the quality in care delivered.

Many different types of records are kept including, those held by patients and parents of young children. Although there are some aspects of writing where there are clear rules, recording is not an exact science. It requires reflection and analysis. Our guidelines are based on what we know from research, inquiries, audit and practice.

Quality in recording

The principles of good record keeping apply to all types of records, regardless of how they are held. These can include:

handwritten clinical notes electronic records

emails

letters to and from other health professionals

laboratory reports

x-rays

printouts from monitoring equipment

incident reports and statements

photographs

videos

tape-recordings of telephone conversations

text messages.

Fax messages

Personal work diaries

Team desk diaries

All ward diaries

Message books

Process notes (learning disability and psychology services)

Video 7Many staff will be registered professionals working to professional codes of conduct, nonetheless all Trust employees will be working within national legislation and Department of Health guidance as well as Derbyshire Community Health services policies and standards. Patient safety and quality in service are paramount. High standards in record keeping are as much a part of that quality service as a reflection of the quality in care delivered.

Footage of DN leaving car, Physio and nurse on ward completing notes

Ben Lobo

Liz Reynolds …’

Remember Courts of law tend to adopt the approach that 'if it is not recorded, it has not been done'.

“If your record keeping is poor, it’s going to impact on your care and therefore the team’s care” says NMC professional adviser Martine Tune

Helen Gaskill

Debbie Brailsford

Heather Worsley

Standards documents footage

Jill White (Includes the list of guidelines on screen)

Bold Screen: Courts of law tend to adopt the approach that 'if it is not recorded, it has not been done'.

Adelle Clements

Elaine Price

Mel Curd

Lyn Barwick

Guidelines

• Hand written records must be written legibly

• Stick to the facts

• Use non-judgemental language

• Be specific

• Use neutral language

• Keep the record intact

• Use verbs to denote an action (e.g. Mrs Bloggs read the paper today) or an occurrence (there is suppuration at the injection site), or a state of being (Mrs Bloggs stood without assistance).

• Use adjectives to give more information about the noun (e.g. Mrs Bloggs sputum is clear/green)

Where possible provide a measure/quantify, or period of time

Substantiate your record with example (s) in support of your judgement Use your senses to record what you did, such as ‘I heard’, ‘felt’, ‘saw’. Use quotation marks where necessary, such as when recording what was said to you. When recording what was stated to you in conversation use the terms ‘alleges’, ‘stated’ or ‘said’

Use only accepted abbreviations

Each entry must demonstrate patient/carer engagement, e.g. ‘Discussed with XXX’, ‘XXXX agreed to XXX ’ ‘XXXX supports decision to refer toXXX’

There is a link to DCHS approved list of Abbreviations,

Staff must keep a clear and accurate record of the discussions they have and the treatment they give and how effective it has been. The progress/evaluation should reflect all care delivered by any member of the team.Examples of where record keeping has been found wanting by the CoronerThere is a link to Coroner Court examples

NMC Fitness to Practice Panel case studies where record keeping has been found wanting :J.Eruvbetere and J.M.Baker There is a link to NMC Fitness to practice reports: Janet Eruvbetere and Judith Marion Baker

There are links to the Community service records & Community Hospital & learning disabilities records.

Working in partnership with patients ‘As long as you can understand and weigh up the information you need to make the

decision, you should be able to make it.’ DH 2001

The Mental Capacity Act 2005 provides a framework to empower and protect people who may lack capacity to make some decisions for themselves. It makes it clear who can take decisions in which situations, and how they should go about this.

Five principles of the Mental Capacity Act 2005 Every adult has the right to make his or her own decisions and must be assumed to

have capacity to make them unless it is proved otherwise. A person must be given all practicable help before anyone treats them as not being

able to make their own decisions.

Just because an individual makes what might be seen as an unwise decision, they should not be treated as lacking capacity to make that decision.

Anything done or any decision made on behalf of a person who lacks capacity must be done in their best interests. 

Anything done for or on behalf of a person who lacks capacity should be the least restrictive of their basic rights and freedoms.

The deprivation of liberty safeguards (DOLS) Code of Practice (the Code) is a supplement to the main Mental Capacity Act 2005. It provides guidance for professionals involved in administering and delivering the DOLS.

This is the link to RCN Legal Advisor Chris Cox’s slides: http://www.rcn.org.uk/__data/assets/pdf_file/0003/156243/Chris_Cox_pp.pdf

There is a link to the FACE guidance and record doc. re mental capacity

Mental Capacity Act 2005 http://www.opsi.gov.uk/acts/acts2005/ukpga_20050009_en_1

http://www.publicguardian.gov.uk/mca/mca.htm

Deprivation of liberty safeguards http://www.publicguardian.gov.uk/about/dols-code-laid.htmhttp://www.publicguardian.gov.uk/docs/draft-dols-code.pdf

See also ‘Good Practice in consent: achieving the NHS Plan commitment to patient-centred consent practice’ DH HSC 2001/023 http://www.dh.gov.uk/en/publicationsandstatistics/lettersandcirculars/healthservicecirculars/dh_4003736

Video 8

Heather Worsley discussed the concern that health care providers may have in assessing a patients capacity to consent

The principle should be adopted that records are completed in such a way that the language and terminology used is understandable for patients, carers and professionals. The record should not contain meaningless phrases, irrelevant speculation, offensive or subjective statements.

Jayne Matthews (Deputy Nurse manager Learning disabilities) describes the

Heather Worsley

HV & parent with red book, other footage of recording in a record

Sally Winter

Learning disabilities patient recording page(s)

importance of engaging those with learning disabilities and communication difficulties in recording. And the value of records when working as part of a multidisciplinary team Jayne Matthews

MDT meeting

Levels 1,2 & upwards, clinical Community Hospital,Community

Clinical Coding

Clinical coding is ‘the translation of medical terminology as written by the clinician to describe a patient’s complaint, problem, diagnosis, treatment or reason for seeking medical attention, into a coded format’ which is nationally and internationally recognised. Codes ensure the information from case notes is standardised and comparable. They are used to support many functions both clinically and statistically including: Clinically- clinical Governance, Clinical Audit and Outcome and Effectiveness of Patient’s care and treatment.Statistically- Payment by results, cost analysis, Commissioning, Aetiology studies, Health trends, Epidemiology studies, Clinical indicators and Case mix planning.

There is a link to the Hospital Activity Data Guide for clinicians

Where the following wording is used in records, it is not possible to attribute a code:

Differential Diagnosis ( ∆∆ ) Possible Likely Maybe Suspected ? Impression

What can be coded is:

Definite Diagnosis ( ∆ ) Treat as Probably Presumed Symptoms where no definite Diagnosis is made

[Still of Tracey Wardle with her title:Patient Systems, Training and Quality Manager]

How you can help ensure accurate clinical Coding?

Ensure that all entries in the case notes are legible and written in BLACK ball point pen.

Ensure the main condition being treated or investigated (the Primary Diagnosis) is listed first on any discharge documentation so that the Clinical coders will put this into the first position on the computer system.

Ensure that the information provided is complete and accurate. It is important that secondary diagnosis and any procedures undertaken are fully documented.

Ensure all co-morbidities are listed

Put the main symptom, abnormal finding or specific problem as the main condition if there is no definitive diagnosis.

There is a link to the Clinical coding:- Best Practice Guide lines

Video 9The translation of medical terminology as written by the clinician to describe a patient’s complaint, problem, diagnosis, treatment or reason for seeking medical attention, into a coded format ensures the information from case notes is standardised and comparable nationally. Clinical coding information is used to support functions both clinically and statistically.Tracey Wardle Patient Systems, Training and Quality Manager explains the

Images of records being completed by a slection of staffTracey Wardle

importance of best practice in record keeping to ensure accuracy in clinical coding.

Levels 2 & upwards, Clinical, Hospital & Community

DCHS Clinical Records Keeping policy states that record keeping is an integral part of a clinician’s clinical practice and duty of care, it is a tool which should aid the care process and should not be seen as separate from this process and is not an optional extra. All clinical records regardless of format or type should protect the welfare of the patient/client by promoting:

High standards of care

Continuity

Better communications between the inter-professional team involved in the provision of care

An accurate account of assessment treatment, care planning and delivery

The ability to identify risks, and detect problems

Confidentiality

And overall reflect the quality of care provided

The principles of good record keeping apply equally to electronic clinical records e.g. The Phoenix Project – TPP / SystmOne /Frameworki

DCHS documentation

The electronic documentation library on the DCHS Intranet contains standardised documentation to be used across all areas in DCHS.

The documentation has been reviewed and formatted to meet the following aims:

-reduce the amount of duplication of documents that have been in use in line with the principles of the Single assessment Process (SAP)

-standardise multidisciplinary team documentation across the DCHS

-ensure all documents are fit for purpose

-ensure the documents will facilitate multi-agency patient centred care

There is a Link to the Community Hospital, Learning disability and Community Documents in electronic documentation library

You may wish to ask your group whoever they are to consider these examples from practice. Ask ‘ in what ways does use of this chart breach organisational and professional standards?’

Link to Scan of the two Sleep Charts (scan 0001 0002)

AnswerThere are many ways in which this document is in breach of organisational and professional standard. You may have identified the following:

This is not a document approved for use in DCHS It has no version control The name of the hospital is not included It does not have three patient identifiers: the patient’s name, NHS number and date

of birth It appears to have been photocopied from a locally devised chart ‘Recordings’ are not signed ‘Recoding’ in the date column has been extended beyond the chart The abbreviations are not ones approved for use in the organisation

e.g. ‘D- Doz’n’ or D- Dozing in chair (might even be read as DOL’n)

In example 1 (Scan0001) how would one account for the patient being recorded as having been A/ST- Awake, Asleep and Up to toilet?

In example 2 (scan 0002) how would one account for what looks like OTS- Incontinent, Up to toilet and Asleep?

Example 2 Also suggests that P –PRN medication has been given. This would not meet professional codes of practice in Standards for Medicines management

Neither example present a picture professional care. Professional credibility and the reflection of high standards in care would easily be undermined in court.

Two examples of ‘Sleep Charts’ approved for use in DCHS can be found by following the link

Quality in Records The pre-course activity may have brought to your attention aspects of good record keeping as well as those that might be improved. This document is taken from In-patient records but the principles are relevant to all areas. Like many records they demonstrate examples of good quality, clear, specific documentation as well as areas for improvementLink to example of an In-patient record (scans 0003-00024)

Review of In-Patient Records

Mobility –Treatment Plan (Link to scans 003-007) Having read the FACE Health Needs assessment and Treatment Plan (Scans 0003 -0007), list what is good and what is not so good about what is written on the Mobility –Treatment Plan page 1(Scan 0006)

Our list: Not all the patient identifier information had been completed Error in recording fractures and their impact on mobility Use of abbreviations including CHS Clear and specific goals Recording initialled Record made of achievement date, time and initialled

Mobility –Treatment Plan page 2 (Scan 0007)This is a good example of where the documentation has been completed, it is specific, clear as to who has performed the treatment, when it has been achieved is dated and initialled.

Washing & Dressing – Treatment Plan (Link to Scan 0008)This page uses the abbreviation CHS for Charnley Hip Screw. This is not an approved abbreviation.Link to approved list of abbreviationsIt is not clear from this record what goals have been agreed with the patient to achieve their optimum level of independence. No specific help is documented, quantified or timed.

Treatment Plan page 1(Link to Scan 0011)

Not all the patient identifier information had been completed The patients actual Waterlow Score is not documented (‘Waterlow is high’) The patients dressing should be recorded in full on the separate Dressing Sheet The Goals Agreed With Patient section. This is good documentation of the Treatment

Plan but has been recorded in the wrong place. This should be recorded on page 2

Treatment Plan page 2 (Link to Scan 0013) Neither Capacity nor Consent sections have been completed. The documentation here again is good but should have been recorded on the

Progress/Evaluation sheet.

Progress /Evaluation (Link to Scan 0014)

This patient is identified by the Physiotherapist as being ‘very deaf’, this should be recorded on the Treatment Plan Index Sheet and/Communication treatment plan.

The quality of information recorded on the Progress/Evaluation sheet is variable. There are examples of good and excellent documentation. These record relevant quality information from the patients daughter (30.9.08 20:00) (Scan 0014) and description of the patients ability and need from the OT student washing and dressing assessment 6.10.08 11:20 (Scan 0018). Excellent use of cross reference is made here to the report in section 7 and updated treatment plan section 8

One less good example where further information would be beneficial to those continuing the patients care would be the recording of care 30.9.08 08:00 (Scan 0014). This might be enhanced by reference to what the patient is able to do for themselves

On 13.10.08 05:00 (Scan 0023) ‘Appears to have slept. Not buzzed during the night’. Does this provide a meaningful account of the patient’s night and care?

This is an unhelpful statement. Had she actually slept most of the night? What is the relevance of not having buzzed? Had pain control been better managed? Was she less disorientated or confused? Alternatively, had she spent most of the night laying awake quietly ? Been unable to reach the buzzer or had she made minimal demands on the nursing staffs time?

What does the final entry on 13.10.08 (Scan 0024) tell us about the patients progress/evaluation ?

Based on this patient’s record and without knowing them, how confident you would feel about continuing their care?

Community Nursing Record

Review these examples of Community Nursing Records for poor practice in the application of the principles of record keeping.Review the Community Nursing Record for Susan Smith –Scans 002-0015. Consider/list where this record falls short of DCHS and national standards in record keepingLink to Community Nursing Record Scan folder in resources 0002-0015

Answer

Community Assessment Link to scan 0015 There is no Activities of Daily Living (A.D.L) assessment There has been no record of this patients nutritional assessment

Service User’s personal details Link to scan 0006 The is no list of current medication

Wound assessment Link to scan 0011 There has been no reassessment of the wound

Waterlow Pressure Ulcer Prevention/Treatment Risk assessment Tool Link to Scan 0009

Both D.O.B and NHS number are missing

Discharge summary Link to Scan 0014 There is no Discharge information

Observations Chart Link to Scan 0013 There has been no record of observations

Pain assessment Link to scan 0012

There has been no pain assessment

Review the Community Nursing Record for George Godson Scans 0001 &0016-0026. Consider/list where this record falls short of DCHS and national standards in record keepingLink to Community Nursing Record Scan folder in resources 0001 & 0016-26

Answer

Patient Information Link to Scan 0001 Patient D.O.B , NHS number, date of admission and date of discharge are missing

Your Community Team Link to Scan 0016 Community Team member designations and contact numbers omitted

Community Team- Staff Signature Sheet Link to Scan 0017 Signatures, initials, date and time missing

Service User’s Personal Detail Link to Scans 0018 & 0019 Missing information

Needs Assessment- Activities of Daily Living Link to Scan 0020 & 0021 Only partially completed

Observation Chart Link to Scan 0022 There are no baseline observations recorded

Care Plans 1 & 2 Link to Scans 0023 & 0024 Care Plan number 1 is incomplete. The quality of what has been written is a poor

record of the plan of care and could not be understood by a subsequent practitioner

Waterlow Pressure Ulcer Prevention/Treatment Risk assessment Tool Link to Scan 0025

Not completed

Evaluation Sheet Link to Scan 0026 Evaluation has factual record of what advice was actually given re eating and

drinking

Principles of writing a good record

Some practitioners record too much...but others too little. Being too brief and concise may mean there is a tendency to over simplify the situation and fail to record what is relevant. Deciding what is relevant, is more complicated than simply writing less. ‘Process recording’ i.e. extensive SOAP notes may lead to writing too much or emphasising unimportant incidents or events.

Consider the relevance of information recorded, the reasons why and the subsequent planned action of care. Lengthy recording might indicate that the practitioner needs to discuss their personal or professional needs with their clinical supervisor.Analysis of the situation allows the practitioner to focus on the ‘depth’ of the interaction rather than on a description of the superficial presentation of what they observe.Critical or negative personal feelings towards patients should not be displayed in the record. These can be distinguished from professional judgements which are validated by description of the evidence on which the judgement is based. Inclusive writing

Have a look at a selection of your own files. Jot down some notes about how you might feel if these were written about you. What might a solicitor make of them?

Example: ‘ latin temperament- low pain threshold’Avoid value laden phrases or those suggesting an irritability on the part of the author.

Major definitional questions in the use of terms such as ‘low ability,’ ‘untidy house’ ‘neglect’ and ‘unresponsive’. Could you qualify the exact meaning of these terms, and if so have you recorded the evidence that substantiates your use of them? Otherwise you might be criticised with labelling the person, but not with universally understood meanings. These might say more about you than the client or patient!

Allegations should be checked before recording as fact

Avoid the words ‘appears’ and ‘clearly’, there may be many reasons that are not ‘apparent’ or ‘clear’ at all about the situation, and may not provide concrete proof of your judgement. Another word to avoid is ‘presents’, it suggests a person is putting on a front to mislead or confuse others. It is unfair and may colour any future reader’s objectivity (refer to Exercise 4 Activity).Use specific language to state what the issues are. A key skill in assessing information is the ability to summarise it. Regular summarising of the contents of the file may have the following advantages:

Enables practitioners to find relevant information quickly without having to hunt through the record for it.

Helps the process of reviewing the case Helps clarify the aim of the care plan Provides summaries for longer reports, multi-disciplinary case reviews and court

reports Helps new practitioners familiarise themselves with patients/clients quickly

Assessment, planning, implementation, evaluation and review of care recording

There must be clear links between the assessment of need and the plan of care, its implementation, evaluation and review. A clear reason needs to be given as to why the approach is considered to be the most suitable. This requires practitioners to be familiar with the results of recent research. Plans and objectives should be SMART i.e.Specific and clearMeasurable (or verifiable)Achievable and realisticRelated to the assessment of need and the overall concernsTime-related (i.e. within what timescale)

Often records lack a sense of planning or direction in the day to day experiences of patients. Good records contain a sense of direction. When looking at a set of records you should be able to gain an impression of what the care has been and where it is going in its plan. Using a model such as SOAPIE or SOAPIER may help organise records

• Subjective – History

• Objective –Examination & Investigations

• Assessment – Diagnosis/Impression

• Plan

• Implementation – Treatment and Advice

• Evaluation – Review

Direction may be lost, because practitioners are consumed with the ‘here and now’ aspects of care and not the longer term aims and objectives. Often there is no overall time-scale for each step of the plan. Is the plan reviewed and updated in the light of changes?Practitioners should also bear in mind, when compiling records that their colleagues rely on the information they record when taking over a patient’s care. This can resolve any uncertainty about how much to write. The frequency and content of entries is determined both by professional judgement and local standards, the test is: ‘If another practitioner were coming to care for the patient for the first time, what would they need to know?’ Colleagues should be able to look at the records and continue caring for the patient in a seamless continuum. An example of good practice from Community Hospitals is a process for the management of admission and discharge recording processes which historically has been time consuming.

Deborah Brailsford, Ward Manager has developed Admission Process and Discharge Process prioritisation schemes which you may wish to adopt in your ward area

Link to RTTC prioritisation flow charts in Resources sectionThe Effective Treatment planning guide  aims to support staff with good practice guidelines relating to  Multi-professional care planning  

OR STANDARD IN YOUR AREA

Link here to Child Health Red Book

Children’s Services Records

Children’s services manage two sets of records; one held by the parent and one owned by the NHS

The information recorded in both should mirror each other. The Parent held record predominantly records advice, information given and outcomes, it should detail when they will next see or have contact from the Health Visitor.

Current paper based Child Health Records are generated electronically following birth notification and sent to the named identified Health Visitor (they are not accessible via the Trust intranet).

Organised and managed in such a way as to comply with all aspects of national and local guidance they ensure that safeguarding record keeping principles are applied to all children’s records.

The development of electronic record systems e.g. SystmOne demands the same high quality in record keeping standards.

Link here to scan of Child Health record Scan 0029, 0030 and SystmOne record Screen shot

Video 10

“ All children have their own health record that is held by the parents, in which they are encouraged to write in their own observations of their child’s progress or health issues. This belongs to the parent but we may have to ask for access to it for court.

It is a record in which all health professionals and the wider children’s workforce are also encouraged to record their contact with the family for continuity of care, especially for multi-agency working partnerships. And to record services delivered as part of The Child Health Promotion Programme. Care needs to be taken that the language is at a level the parent can understand, that it is legible and also the content easily recognised.

Health visitors also keep a fuller record that belongs to the organisation but its content must mirror whatever they have recorded for the parents in their record. Parents can have sight of this and it should be completed

Parent held record-Red book

Alison Higley footage with ‘mother’

Gail Walker

openly with parents wherever possible. This record will follow the child once it commences full time education and transfer to the named school nurse is the responsibility of the health visitor”

Still of HV Child Health record from Shots taken of records

Rosie Trainor

Mel Curd

Levels 2 & upwards, Clinical Community

Text messaging

The Royal College of Nursing (RCN) Guidance on text messaging acknowledges that: ‘Nurses, midwives and health visitors working in a variety of environments might want to use text messaging services for communicating with children and young people’. It goes on to say; ‘all messages should be documented and include the following information:text, telephone number,time, response, any appointment made and/or referral to other agencies, date and signature of nurse’.

This should then be treated as any other client documentation in keeping with NMC guidelines on record keeping (NMC, 2005). Documentation may be written, but a computer generated system with short messaging service software may be preferable.‘all received messages should be deleted from the receiving handset after documentation to maintain high standards of confidentiality’.

Appointment reminders by Text

Texting client’s reminders of appointments has been shown to successfully reduce DNA and NA contacts by the health visiting team.

Guidelines for texting

1. Staff to have an nhs.net email account2. Staff to have training on the nhs.net texting3. NHS email to be used for texting only.4. NHS texting only to be used for appointments – no sensitive information to be sent.5. NHS texting for appointments to be sent 24 to 36 hours prior to the appointment.6. NHS texts to be sent during normal working hours.7. Standard text message for each service to be agreed (see below).8. No names or personal details to be given in the text (many clients change their

mobile telephones regularly)

9. Check nhs.net email for success or failure of delivery.10. Follow-up failed delivery of text messages to check mobile telephone number

Benefits of use NHS.net for texting

1. NHS mail texting is easy to use2. NHS mail texting is a quick method of sending numerous texts.3. NHS mail texting is achieved using a keyboard4. Secure site for patient information5. Clients/patients receive a text stating NHS6. Clients /patients cannot respond to the text7. Text receipt is sent to staff email account 8. Failed delivery of text notice is sent to staff email account

Text message – appointment reminder examples

Good morning, this is a reminder for your (insert type of appointment eg eye………………………. ) appointment tomorrow at ……………………….. Thank you

Good morning, this is a reminder for your (insert type of appointment eg dental……………………….) appointment tomorrow at ………………………..

If you cannot attend please contact (…………………………….) on 01246 ……….

Thank you

ActivityHere are three examples of text messages sent to school age children, how would you record them ?

1.  Hi -------, just to let you know meeting arranged for------. J*****, school nurse.  

2. ‘don’t forget your appointment at 10.30 today x d******

3.  ‘Hi, just a reminder text about your appointment on Monday, please bring your diet sheets with you. B***********, School Nurse’

Answer: These examples would be written up generically by stating in the child’s health record that the child had been sent a text message reminding them of their impending appointment and any other information on the text e.g. venue/ things to bring etc.

Example of a received text and its response:

Text:” hello you know when you go to get the pill from your GP do you have to be registered to a doctors or can you just go in?”

Response: “ yes you usually have to be registered with GP but you can get the pill by going to Sexual health on Mondays, 4.30pm, Connexions on XXX St, or Emergency contraception at a XXX chemist, does that help” 

Texts are written up verbatim in the child’s health record and then ‘long hand’ and the outcomes of the text.

For example -  ‘received a text about information required re the morning after pill. Responded to text and made an appointment to follow up this enquiry.’

Currently DCHS School nurses do not have access to an automated text messaging service, all text messages are sent via work mobiles. School nurses who do not have access to work mobiles do not send text messages to young people.

Consider how you would record receipt of the following two text messages:

1. “ aup its v****, whats the number for the doctors on south street take care v****** “

 

2. “ have me and c**** got an appointment today “

 Facsimile (fax)

If it is necessary to send information by fax, this must be done to a Safe Haven. The sender must notify the recipient (or duly authorised person) prior to transmission. Once the transmission is sent the sender must then contact the recipient to confirm receipt.Only the minimum amount of relevant information required by the recipient must beincluded.

Video 11

If it is necessary to send information by fax, the sender must notify the recipient prior to transmission. Once the transmission is sent thesender must then contact the recipient to confirm receipt.Only the minimum amount of relevant information required by the recipient must be included.Tissue viability nurse Anthea Baker

Anthea Baker on Tissue viability faxes

Anthea Baker

describes the importance of good quality information in referral, communication and Tissue viability record keeping

Activity- compare these examples received by the tissue viability service:Link to TV poor example Link to TV good example

Level 1, 2 & upwards Clinical, Hospital & Community

Abbreviations

The NMC makes it clear in Record keeping: Guidance for nurses and midwives (July 2009) that unnecessary abbreviations should not be used. Dimond suggests that this advice is probably unrealistic in view of the many abbreviations used automatically and reasonably safely e.g. BP (blood pressure), T (temperature).

But there are dangers in using abbreviations, what would you suggest are the meanings of the following:

1. PID

2. Pt

3. CP

4. MS

5. NFR

6. NAD

7. PCXR

These abbreviations may be dangerously misleading, you may have come up with the following possibilities and more

1. PID: pelvic inflammatory disease or prolapsed intervertebral disc?2. Pt: patient, physiotherapist or part time?3. CP: cerebral palsy or chartered physiotherapist?4. MS: multiple sclerosis or mitral stenosis?5. NFR: not for resuscitation or neurophysiological facilitation of respiration? 6. NAD: nothing abnormal detected or not a drop? 7. PCXR: primary chest X-Ray or portable chest X-ray?

You may know of local defamatory abbreviations too!

Would you like to be in the position of clarifying these meanings to patients, their families, the coroner and court?

Brigid Dimond suggests that what is essential is that there should be an agreed list set up by each directorate or Trust

Derbyshire Community Health Services staff should use only the abbreviations or acronyms approved by the Trust

The link here is to DCHS list of approved abbreviations

The NMC states that abbreviations are just one of the ‘short forms’ that are often used by nurses and midwives. Types of ‘short forms’ include acronyms, initialisations and other forms of text reduction. The use and management of short forms is inconsistent and there is no point of reference for acceptable, official or universally accepted short forms in healthcare.

‘We do not believe it is possible to provide an approved list of abbreviations for all nurses and midwives across the UK. However, at a local level, it is important that abbreviations are unambiguous and universally understandable and do not rely on the context to give the meaning.’ NMC

Abbreviations put patients lives at risk because abbreviations can have more than one meaning or might be misread. A recent US study of 30,000 medication errors, some fatal, showed 5% were linked to abbreviations in notes. Common errors included abbreviating drug names and doses

Link is made here to examples of abbreviation errors

Levels 1, 2 & upwards, Clinical & Non clinical, Hospital & Community

Video exercises

Here are a series of exercises based on short video clips. They have been selected to show a range of different practice situations, each of which presents a particular challenge for the recording of ‘free text’. Of course no video can fully portray the complexity of real life situations. In practice professional judgements are made on the basis of a wide range of information, not simply what we see and hear. However, the video clip activities allow you to practise your recording of situations you may face in your day to day work.

Although the video clips may not directly reflect your individual practice situation, you are encouraged to try a selection of the recording exercises. The principles of effective recording are the same no matter what the practice setting.

You may need to down load/print the appropriate set of clinical records from the intranet or resources section for video clips 1, 2, 3 & 4 in advance of this exercise

Levels 1, 2 & upwards, Clinical & Non clinical, Hospital & Community

The video clips

Clip one Levels 1, 2 & upwards, Clinical Hospital & Community

This clip shows Andrew, a young man with learning disabilities on day three following surgery to close a hole in his heart. The Charge Nurse discusses Andrew’s progress and plan of care.

Use a copy of your records to record this contact

Link to in patient Progress Evaluation sheet and LD records

Link to video clip one

Having completed the mandatory fields in the Progress/ Evaluation sheet we would expect to see all entries to have a date and time and a treatment plan number recorded. Followed by any comments and details that relate to that aspect of care followed by initials.

Eg.

Date and time

Treatment plan number

Comments/details Initials

1.1.10 1 Prescribed analgesia given PRN at 10:00 with good effect. Andrew states that his pain is reducing---------

DM

2 Neck drains removed today, Treatment plan discontinued-----------------------------------------------------

DM

3 Andrew has walked 5 metres with assistance of one twice this morning---------------------------------------------.

EJ

4 ‘Bubble blowing’ exercises for lung expansion undertaken for 1 minute twice this morning. Oxygen therapy to continue. Review in 24hrs--------------------- EJ

5 Catheter to be removed this evening as protocol------ DMAndrew consented to all care today. Family have visited, his care and progress discussed and agreed with Andrew and family--------------------------------------- DM

You might also consider the use of the Learning and Communication Difficulties records Links to LD records

Clip two Levels 1, 2 & upwards, Clinical & Non clinical, Hospital & Community This clip shows an incident in a Trust laboratory where a member of staff suffers a serious injury

Use the Incident reporting forms taken from the Incident book Scan 0027 and 0028 to record your report of this incident

Link to Scan 0027 and 0028

Link to video clip two

Incident ReportAfter completing the mandatory fields we would suggest the following is recorded under Section A: Incident DescriptionDuring a chemistry sampling training session, instructor forced waste paper into a domestic bin, sustaining a laceration to his medial right wrist from glass fragments incorrectly placed there earlier. Injury resulted in moderate blood loss and trainer appeared faint.

Section B: Remedial action undertaken or requiredFirst aid administered, pressure applied to site, arm elevated and ambulance called. Contents of bin safely disposed of. Additional bins provided for hazardous sharps/glass. Disposable gloves provided in first aid kit. Signage for disposal of glass or other sharps erected. Outline of incident shared with others to ensure standardised waste disposal available in all relevant areas.

Clip three Levels 1, 2 & upwards, Clinical & Non clinical, Community

In this clip four month old Oscar is having his childhood immunisations

Link to video clip three

Use a copy of the Child Health Record Scan0029 and Scan 0030 or SystmOne (sample) and the Parent held Record - Red book page 14 and page 41 to see where you would record Oscars immunisations. Consider how this would be done and what free text you would record

LINK to Child Health Record scan 0029 and 0030 SystmOne Screen shot and Red Book link in resources file

We would suggest you record in the Child Health Record or on SystmOne as follows:

1. Vaccine name : DTaP/IPV/Hib, (Diphtheria, Tetanus, acellular Pertussis [whooping cough], Inactivated Polio Vaccine, Haemophilus influenzae b [Hib]

Batch number Expiry date Dose administered Site used

Date immunisation was given

Name and signature of vaccinator

2. Vaccine name : Men C (Meningococcal C) Batch number Expiry date Dose administered Site used

Date immunisation was given

Name and signature of vaccinator

3. PCV (Pneumococcal conjugate vaccine) Batch number Expiry date Dose administered Site used

Date immunisation was given

Name and signature of vaccinator

Include a clear description of which injection was administered in each site, especially where two injections were administered in the same limb

Counselling, consent and management of adverse reactions e.g. Cooling

advice

Also complete any other Childhood immunisation communication documentation you might be using

Note Red Book immunisation pages are printed as per the national immunisation schedule at the time of the childs birth. It may be necessary to insert vaccines that are subsequently added to the programme.

Clip four Level 1, 2 & upwards Clinical, Hospital & Community

Clip four shows events of a day in the life of Phyllis McCormack in a long stay unit

Use a copy of your records to record this contact

Link to in patient Progress Evaluation sheet and LD records

Link to video clip four

Having completed the mandatory fields in the Progress/ Evaluation sheet we would expect to see all entries to have a date and time and a treatment plan number recorded. Followed by any comments and details that relate to that aspect of care followed by initials.

Facilitator note: You may wish to discuss with your group that the Treatment Plan number will reflect the priorities for this patient. Also the entries where it has been identified that a review is required by the doctor

Date and time

Treatment plan number

Comments/details Initials

1.1.10 5 Phyllis was bathed with the assistance of two nurses this morning. Assistance was given with all aspect of washing and dressing as she is unable to undertake any of these activities for herself.

DM

1.1.10 1 Phyllis demonstrated non verbal signs of pain on movement. Prescribed analgesia to be reviewed by doctor.

KI

1.1.10 3 Phyllis had a half portion of her lunch and refused the rest. Remains on a soft diet , full assistance required to eat and dink

EJ

1.1.10 4 Phyllis remains immobile, bed rails continue to be required.

EJ1.1.10 2 Phyllis is listless, distant, tired and tearful at times.

She is sad and withdrawn, seldom interacting with nurses. To be reviewed by doctor.

KI

1.1.10 6 Phyllis continues to require assistance and supervision to take her prescribed medication.

DM

Good record keeping to support the legal process Any records taken in the course of work are a potential legal document and could be used in court If they contain judgemental, vague or unsubstantiated information, it becomes difficult to maintain professional credibility in court. It is the job of the patient’s lawyer to undermine a health professionals case by casting doubt on their credibility. Lawyers are familiar with court

cases and professional hearings, two scenarios that may be intimidating for those who are not. Before a legal case becomes a formal hearing, the records will have been read and studied and an impression formed regarding the relative professionalism of the author. If records are clearly unprofessional it is easier to extrapolate that the same lack of professionalism would be reflected in attitudes towards patient care.

Adapted from The importance of good record-keeping for nurses. C. Wood.Nursing Times.net January 2003

Levels 2 & upwards, Clinical, Hospital & Community

Video 12 ‘ Melanie Curd, Head of Integration describes how good record keeping supports the legal process, helping health professionals prepare statements for Court; Coroner’s court, Children’s court or Court of protection’.

Image of ward sister and Physio reviewing notes, health visitor and mother looking at red book

Melanie Curd S2, S3 S4

Poss Liz Reynolds S7

Heather Worsley S10

Requests for formal statements

Any requests to staff from outside agencies to provide statements or attend court should in

the first instance be referred to the Directorate Manager and the Legal Services Manager for

further guidance and advice, as occasionally, it will not be appropriate to reply to a request.

There may be occasions where statements will be required for child or adult protection cases

and in these circumstances the cooperation of staff is important. Guidance in these

instances should be sought from the senior manager and the adult/child protection team.

The basic principles for staff who has been requested to prepare a formal witness statement

for proceedings or hearings or who has been called to give evidence in court are laid out in

the DCHS Guidelines for staff writing witness statements or giving evidence in court For all

legal matters relating to the Trust, it is important that staff should inform their direct line

manager and the Legal Services Manager.

What should the statement contain?

Your statement should include the following points:

Name of the person writing the statement

Position and qualifications (without abbreviations)

Date of statement

Normal place of work

Identify the subject/patient using patient details and date of birth

Deal with the matters relevant to the question or case with a logical chronological

story of events

Stick to the facts making clear what is within your direct knowledge

Avoid criticism of systems/processes/colleagues and other departments/agencies

Use the first person singular (I) as this minimises ambiguity

Avoid using medical abbreviations or jargon, simple grammar is required

End the statement with the last encounter with the subject matter, unless further

detail will aid clarity

Principles to be followed in preparing a statement

• Accuracy

• Factual

• Avoid hearsay

• Conciseness

Relevance

• Clarity

• Legibility

• Overall impact

• Keep a copy

Essential elements of a police statement

• Full name of maker, grade and qualifications

• Date and time of consultation

• Date, time and details of incident - as told by patient – “ He stated….”

• Findings on examination

• Details of investigations and findings

• Treatment prescribed

• Referral or discharge plan

Signature

BOLD ACROSS SCREEN:

For all legal matters relating to the Trust, it is important that staff should inform their direct line manager and the Legal Services manager.