Documentation and record keeping

Transcription

1 KEYWORDS Records / Documetatio / Accoutability Proveace ad Peer review: Commissioed by the Maagig Editor; Peer reviewed; Accepted for publicatio November Documetatio ad record keepig by Susa Pirie Correspodece address: Susa Pirie, Practice Educator (Theatres), Surrey ad Sussex Healthcare NHS Trust, East Surrey Hospital, Caada Aveue, Redhill, RH1 5RH. [email protected] Documetatio ad record keepig is a importat aspect of healthcare practice ad perioperative practice is o exceptio to this rule. For some time ow, recordig every activity or itervetio that a patiet receives has assisted with ehacig perioperative practice; equally, it has played a key part i resolvig legal ad professioal icidets that have occurred. There are umerous atioal guidelies that uphold accurate record keepig as a itrisic aspect to patiet safety (DH 2006, HPC 2008, NMC 2008, Scottish Executive 2008, DH 2009). The itetio of this article is to idetify ad discuss some of the more commo errors associated with record keepig which may have a direct or idirect effect o practitioers miscoceptios of usig electroic record systems. Defiitios It would seem appropriate firstly to cosider what is meat by the terms documetatio ad record keepig. The Collis Eglish dictioary (2003) defies documetatio as documets supplied as proof of evidece of somethig. Records have bee defied as a documet or other thig that preserves iformatio (Collis Eglish Dictioary 2003). Record keepig has bee stated as part of the professioal duty of care owed by urses to the patiet (Dimod 2008). Guidace for good record keepig Havig idetified what is meat by the term record keepig, practitioers should be aware that the Nursig ad Midwifery Coucil (NMC) cosider that Good record keepig is a itegral part of ursig ad midwifery practice, ad is essetial to the provisio of safe ad effective care. It is ot a optioal extra to be fitted i if circumstaces allow (NMC 2009). Give the importace of accurate documetatio ad records, practitioers should be aware of the guidace i Box 1 i relatio to completig records: Commo errors i record keepig Havig established what a record is ad how it should be completed, it may be helpful to cosider some of the pitfalls ad bad habits that ca affect effective documetatio ad record keepig. These are particularly pertiet i the evet that patiet documetatio eeds to be reviewed i a adverse icidet. Some of the more commo errors ca be foud i Box 2. All patiets records should provide a clear accout of the patiet s care at a particular poit i their healthcare ecouter. I additio, they should provide a comprehesive ad relatively cocise record of what has occurred. It is ackowledged that some urses feel that record keepig is a oerous task that prevets them from providig care to the patiet (Dimod 2008, Taylor 2003). However, it should be remembered that ursig documetatio is a key elemet of ursig practice, as well as a key commuicatio strategy betwee healthcare professioals (Marti et al 1999, cited i Taylor 2003). Now that the importace of records has bee idetified it is pertiet to cosider the types of documetatio that are used withi the perioperative eviromet. Types of record There is a wide rage of records i the perioperative eviromet relatig to the pre, itra ad post operative periods of care. I the preoperative phase, records such as the checkig of aaesthetic equipmet ad checkig of cotrolled drugs as well as the aaesthetic record will be completed. The aaesthetic record will usually be completed by the aaesthetist or o some occasios by Review Idetify the relevat professioal regulatory body advice o documetatio ad record keepig as well as reviewig your orgaisatio s policies ad protocols to esure that you are familiar with these requiremets. Notioal Learig Hours 1 hour Kowledge ad Skills Dimesio Core: Commuicatio Core: Persoal ad People Developmet 22 Jauary 2011 / Volume 21 / Issue 1 / ISSN

2 A record that begis with the preoperative phase ad cotiues ito the itra ad post operative phases is the perioperative care pla All etries should be clear ad legible Etries should be siged ad if this is your first etry i a record, you should documet your ame ad job title Records should be completed i lie with local policy Etries should be accurate ad the meaig of your etry should be clear to all idividuals ivolved i the care of that patiet Records should be factual ad ot based o opiio Practitioers should use their professioal judgemet to cosider what iformatio should be recorded The relevace of the iformatio should be cosidered both i relatio to the patiet s care ad also to other healthcare professioals ivolved i carig for the patiet Records should provide a accout of the care give, ay assessmets that have bee made as well as the requiremets for ogoig care They should be able to provide a comprehesive but cocise record of the care that has bee give Patiet records should idetify ay problems ad how these have bee resolved Where it is feasible ad appropriate to do so, patiets or their carer should be ivolved i the record keepig process Records should use appropriate laguage so that they ca be easily uderstood by all who have access to them Records should ot be altered or destroyed uless a practitioer has the authority to do so I the evet that a etry i a patiet record requires amedmet, the this should be doe without defacig the origial etry which should still be readable Ay alteratios must be dated ad siged ad the practitioer udertakig the alteratio must specify their ame ad job title Records should ot be falsified i ay way Records should always be readable, particularly if they have bee photocopied or scaed Box 1: Guidace for good record keepig. Source: Nursig ad Midwifery Coucil 2009 Illegible hadwritig Delays i completig the patiet record (records have bee completed up to 24 hours or more after a evet) Completed by someoe who has ot delivered the care documeted Lack of sigature Iaccuracies i dates ad times Iaccuracies i patiet idetificatio iformatio such as wrog date of birth, misspellig of ames Iappropriate laguage Ambiguous abbreviatios Opiio mixed with facts Subjective, ot objective observatios. Box 2: Commo errors i record keepig. Source: Dimod 2008 Patiet details Ward checks prior to leavig for theatre Checks from the receptio area o arrival i theatre Checks i the aaesthetic room ad the positioig of moitorig equipmet The positio of the patiet for the perioperative itervetio or procedure ad the aids that have bee used to facilitate this positio Ski itegrity ad coditio, particularly aroud the diathermy site Iformatio o the cout The type of touriquet used ad the duratio of use Details of specimes that have bee take Iformatio o woud drais, dressigs, catheters, stomas ad plaster casts. This is ot a exhaustive list but will give a idicatio of some of the iformatio that is required to be documeted durig a perioperative itervetio or procedure. Box 3: Iformatio cotaied withi the perioperative care pla the physicia s assistat i aaesthesia. Guidace o the iformatio that should be recorded i this documet is available from the Associatio of Aaesthetists of Great Britai ad Irelad (AAGBI 2008). Perioperative care pla A record that begis with the preoperative phase ad cotiues ito the itra ad post operative phases is the perioperative care pla. This may be a electroic record, a paper record or a combiatio of both. This documet will provide a comprehesive record of the patiet s time i the perioperative eviromet ad the iformatio it is likely to cotai ca be foud i Box 3. The cout Traditioally the cout, that is, the recordig of items used durig the surgical procedure, Jauary 2011 / Volume 21 / Issue 1 / ISSN

3 Documetatio ad record keepig Cotiued has bee marked up o a white board i theatre. At the ed of the operatio, the accuracy of the cout will be recorded i the theatre register ad the perioperative care pla. The record will traditioally be made by the sigature of the scrub ad circulatig practitioers who have performed the relevat cout, ad will ot cotai a record of the items utilised ad icorporated ito the cout. May perioperative departmets have ow itroduced a system whereby the cotet of the cout is recorded o paper as well as o a white board, so that a permaet record of the cout is retaied i the patiet s otes. This practice has had a sigificat impact o patiet safety as it provides a clear record of all the items used i the cout as well as idetifyig the practitioers who have bee ivolved (AfPP 2007). Decotamiatio records Decotamiatio records are also kept to esure compliace with trackig ad traceability requiremets. This is ofte a separate record i which both the trackig label for the tray ad/or supplemetaries ad the decotamiatio label detailig the autoclave ad sterilisatio data are placed. Agai, this record is placed i the patiet s otes. Records of implats or protheses May procedures ivolve the use of implats or prostheses ad there are a umber of regulatios ad recommedatios that eed to be complied with i relatio to the recordig of these items. Orthopaedic joit implats are ow required to be logged cetrally o the Review Idetify the potetial areas of risk relatig to icorrectly completed documetatio. Notioal Learig Hours 30 mis Kowledge ad Skills Dimesio Core: Commuicatio Core: Quality Natioal Joit Registry database. There are a umber of record keepig requiremets that are liked to the Cosumer Protectio Act 1987 such as those listed i Box 4. Equipmet related records Aother importat area of documetatio is less obvious to the perioperative practitioer, but remais importat, ad that is equipmet related records. These records are ofte held outside the perioperative departmet as they are joitly maaged with the estates departmet, medical physics or bioegieerig departmets, medical device compaies or decotamiatio uits. The cotet for these records ca be foud i Box 5. The specific implat or prosthesis, icludig the size The maufacturer of the implat or prosthesis The code umber The batch ad/or lot umber The sterilisatio date ad/or date of maufacturer The expiry date of the implat/prosthesis Ay amedmets or adaptatios that have bee made. Box 4: Record keepig requiremets for implats ad prostheses. Source: Associatio for Perioperative Practice 2007, 2009 The date ad record of purchase Idetificatio umbers for effective tracig ad trackig throughout the life of the equipmet Maiteace records Capital assets registry umber if listed as a capital asset Details of the maiteace cotract ad its reewal date The programme for plaed maiteace Calibratio records ad schedules Details of loa equipmet Records of ay items set for repair. Box 5: Requiremets for equipmet related record keepig. Source: Associatio for Perioperative Practice 2007, 2009 Safer Surgery Checklist The eed to be vigilat i relatio to patiet care has always bee a focus for perioperative practitioers, but a additioal record has bee created with the itroductio of the World Health Orgaisatio Safer Surgery Checklist. This has bee adapted by the Natioal Patiet Safety Agecy (NPSA) for use i Eglad ad Wales ad cosists of three separate sectios: Sig i, Time out ad Sig out. The importat elemet of this process is the surgical pause durig the time out phase, whe the multidiscipliary team pauses as essetial patiet safety iformatio is checked, prior to the start of the perioperative itervetio or procedure (NPSA 2009). I Scotlad, the Scottish Patiet Safety Alliace has istituted a similar system with the perioperative briefigs where all team members itroduce themselves ad issues are discussed. As with the system i Eglad ad Wales, a surgical pause is iitiated immediately prior to kife to ski (Scottish Patiet Safety Programme 2008). Theatre registers Theatre registers are aother form of documetatio that must be completed. The register will documet the followig: The patiet s ame, date of birth, hospital umber The procedure that has bee completed, icludig the aaesthetic type The ames of the aaesthetist (s)ad surgeo(s) ivolved The ame of the scrub ad circulatig practitioers ivolved i the cout Details of ay implats Details of ay adverse icidets that have occurred (AfPP 2007, AfPP 2009). May perioperative departmets o loger use a paper based register ad record all of the above iformatio o a electroic record. This kowledge has bee gaied from persoal experiece as a perioperative practitioer, by talkig to other perioperative practitioers across the UK ad by visitig perioperative departmets where such a system is i use. This ca cause cocer to some practitioers, who feel that it is ecessary for them to physically sig the register. However, it remais the resposibility of every practitioer, to esure that records about the care they provide are 24 Jauary 2011 / Volume 21 / Issue 1 / ISSN

4 Care should be take ot oly to record appropriate iformatio, but also to esure that appropriate ad meaigful laguage is used accurate ad complete. Therefore a electroic register should be checked i the same way as a paper register ad by ackowledgig that the iformatio is correct, this should act as cofirmatio that the record is correct i the same way that a sigature o paper record sigifies this. The NMC has published guidace i relatio to the use of iformatio maagemet systems, which will iclude the use of electroic records (NMC 2009). Oe elemet of electroic records that should be strictly adhered to is the cofidetiality of passwords ad smart cards. Smart cards are used by authorised staff to access the NHS electroic record, ad are uiquely idetifiable to the practitioer to whom they have bee issued. Smart cards are curretly beig issued to staff i the writer s trust, as a ew electroic theatre record will be itroduced early ext year. The ew system will require the use of smart cards i order to access the ecessary records ad to eter patiet iformatio i that record. Uder o circumstaces should these be divulged to or used by ayoe else, or should they be left i a system so that others may eter iformatio or amed iformatio that you have already etered (NMC 2009). Legal implicatios There are a wide rage of legal implicatios i relatio to the documetatio of care ad Reflect Reflect o your persoal documetatio ad record keepig practices ad idetify ay chages you may eed to make, by reviewig the iformatio you record. Notioal Learig Hours 1 hour Kowledge ad Skills Dimesio Core: Commuicatio Core: Persoal ad People Developmet HWB 5: Provisio of care to meet health ad well beig eeds the record keepig requiremets of healthcare practitioers. This article does ot discuss all of these elemets but gives a broad overview of the mai requiremets icludig the defiitio of legal documets, the eed for clarity ad accuracy, the role of the Caldicott Guardia, ad the retetio periods for records. It also highlights some of the more importat legislatio relatig to healthcare records. Practitioers who require iformatio o coset should refer to atioal guidelies (DH 2001, DHSSPSNI 2003 ad SEHD 2006). What is a legal documet? I the first istace it is helpful to clarify ad defie what is a legal documet? The aswer is somewhat complex as certai documets, such as patiet s case otes ad theatre registers, are clearly defied as legal documets, whereas there is cofusio over the status of may of the documets we use o a daily basis. Dimod (2008) has stated that a legal documet is ay documet requested by the court ad goes o to idetify some of the documets ad records that may be requested. I the perioperative settig, ay of the documets we complete, may be requested by the courts ad so it is essetial that all records are completed correctly. It is a kow fact that poorly completed records will impact o the professioal cocered i the evet that they are questioed about documetatio i a court of law (Dimod 2008), where they will be required to state the truth cotaied withi the record, uder oath i a court. Implicatios of record keepig Practitioers may wish to cosider the implicatios of records i the case of Deaco v McVicar. I this case the patiet alleged that there were a umber of cocers relatig to her care, particularly the removal of the Shirodkar suture, which eeds to be removed as soo as labour has commeced, i order to prevet damage to the cervix. The patiet did ideed suffer damage to her cervix ad claimed that this was due to the failure of staff to atted to her promptly ad that the perceived delay i removig the suture resulted i her ijury. The defedats claimed that although the labour ward was busy, her care was ot compromised. The judge cocered ordered that the records of other patiet s o the ward at the time of the icidet should be disclosed to the courts i order that a assessmet of the demads o staff at this poit i time could be made (Dimod 2008). It has bee demostrated above, that good record keepig is essetial as the umber of medical egligece cases cotiues to rise. Figures from the NHSLA Aual Report for 09/10 show that the total costs paid out i this period i relatio to cliical egligece schemes was almost 787 millio. It is the third year i successio that the figure has rise; 633 millio ad 769 millio were paid out i 07/09 ad 08/09 respectively (NHSLA 2010). It must be remembered that i medical law, if a care procedure has ot bee documeted the it has ot occurred (Wood 2010). The clarity of iformatio i records is essetial (Dimod 2008). Care should be take ot oly to record appropriate iformatio, but also to esure that appropriate ad meaigful laguage is used. Care should be take i relatio to the use of abbreviatios, for example ESR may relate to erythrocyte sedimetatio rate or electroic staff record, a cofusio that has occurred i the writer s workplace. Similarly the eed for accuracy i what has bee recorded has bee highlighted earlier i the text, particularly i documetatio that is used by the multidiscipliary team. Documet retetio periods The retetio periods of documets vary eormously ad there are specific legal guidelies for some perioperative documets. Some of these requiremets ca be foud i Box 6 Accoutability It is ofte the case that there is a degree of cofusio amogst staff over the level of accoutability that healthcare practitioers hold, ad a commo miscoceptio is that oly registered practitioers are accoutable. I relatio to professioal accoutability, this is a accurate assumptio as it is oly the practitioers who are regulated by a professioal body that are held accoutable to that orgaisatio. However, it should be remembered that everyoe regardless of professioal status has a legal duty of care to each other. I additio, all employees are accoutable to their employer who will expect them to work withi the policies ad protocols of their orgaisatio. Registered urses ad operatig departmet practitioers are regulated by the Nursig ad Midwifery Coucil ad the Health Professios Coucil respectively. I Jauary 2011 / Volume 21 / Issue 1 / ISSN

5 Documetatio ad record keepig Cotiued order to maitai their registratio, registrats are required to work withi the guidace provided i the code or stadards of these orgaisatios. Registered urses must comply with The Code: Stadards for coduct performace ad ethics for urses ad midwifes (NMC 2008); operatig departmet practitioers are required to comply with the guidace i Stadards of coduct, performace ad ethics (HPC 2008). The requiremets of these bodies ca be foud i Boxes 7 ad 8 respectively. Keep clear ad accurate records I additio, the NMC has provided further guidace for registrats i the documet Record Keepig Guidace for Nurses ad Midwives (NMC 2009). This documet provides a greater isight ito these requiremets ad provides further guidace o the kowledge requiremets that registrats should be familiar with. The Health Professios Coucil guidace for accurate record keepig is cotaied withi the documet Stadards of coduct, performace ad ethics (HPC 2008). It ca be foud i Box 8. Coclusio This article provides a overview of some of the mai requiremets relatig to professioal stadards of documetatio ad record keepig ad idetifies some of the documetatio that requires completio i perioperative practice. It is aticipated that this article will provide a resource to practitioers who ca the exted their kowledge further by reflectig o their ow ad their orgaisatio s practice i relatio to these issues. It is hoped that the further readig list may be of assistace to them i this process. Refereces Associatio of Aaesthetists of Great Britai ad Irelad 2008 Iformatio Maagemet: guidace for aaesthetists Lodo, AAGBI Associatio for Perioperative Practice 2009 Safeguards for Ivasive Procedures Harrogate, AfPP Associatio for Perioperative Practice 2007 Stadards ad Recommedatios for Safe Perioperative Practice Harrogate, AfPP All records pertaiig to childre ad youg people should be retaied util the patiet s 25th birthday or util 8 years after death If treatmet is cocluded whe the patiet was aged 17 at the coclusio of treatmet, the records must be kept util the patiet is 26 years of age Cotrolled drug documetatio should also be kept for specific periods of time, ad advice o these retetio periods should be sought from the pharmacy departmet as it is probable that the retetio ad storage of these drugs will be withi their domai Edoscopy records must be kept for a period of 8 years or i accordace with guidace o records for childre if paediatric patiets have bee treated withi these records These records must also iclude sterilix edoscopy disifector traceability strips ad the traceability strips for PEG/stets that are used i edoscopy Joit replacemet records eed to be kept for 10 years Operatig theatre lists should be kept for 4 years if they are oly available i a paper format, ad paper copies of electroic theatre lists should be kept for a miimum of 48 hours Operatig theatre registers should be kept for a miimum of eight years if they relate to adults oly Operatig registers with details of paediatric cases should be kept i lie with the recommedatios for childre ad youg people Obstetric operatig theatre registers or those that cotai obstetric patiet records, should be kept for 25 years after the birth of the child Records that cotai batch iformatio o products should be kept for 10 years Refrigerator temperature records should be retaied for a period of oe year, although records relatig to the products stored withi a refrigerator should be kept for the life of the products i.e. util the expiry date Photographs that are prited ad placed i the patiet s otes should be retaied i lie with the retetio period relevat to the patiet Recovery room records eed to be retaied for a miimum of 8 years Box 6: Guidelies for retetio of perioperative documets. Source: Departmet of Health 2009 You must keep clear ad accurate records of the discussios you have, the assessmets you make, the treatmet ad medicies you give ad how effective these have bee. You must complete records as soo as possible after a evet has occurred. You must ot tamper with records i ay way. You must esure that ay etries you make i someoe s paper records are clearly ad legibly siged, dated ad timed. You must make sure that ay etries you make i someoe s electroic records are clearly attributable to you. You must esure that all records are kept securely. Box 7: Keepig clear ad accurate records. Source: Nursig ad Midwifery Coucil Jauary 2011 / Volume 21 / Issue 1 / ISSN

6 If you update a record you must ot delete iformatio that was previously there You must keep accurate records Makig ad keepig records is a essetial part of care ad you must keep records for everyoe you treat or who asks for your advice or services. You must complete all records promptly. If you are usig paper-based records, they must be clearly writte ad easy to read, ad you should write, sig ad date all etries. You have a duty to make sure, as far as is possible, that records completed by studets uder your supervisio are clearly writte, accurate ad appropriate. Wheever you review records, you should update them ad iclude a record of ay arragemets you have made for the cotiuig care of the service user. You must protect the iformatio i records from beig lost, damaged, accessed by someoe without appropriate authority, or tampered with. If you update a record you must ot delete iformatio that was previously there, or make the iformatio difficult to read. Istead you must mark it i some way (for example, by drawig a lie through the old iformatio). Box 8: Keepig accurate records. Source: Health Professios Coucil 20 It ca be see therefore that these two documets provide clear guidace i relatio to the stadards of documetatio ad record keepig that registrats are required to comply with. Collis Eglish Dictioary 2003 Glasgow, HarperCollis Publishers Deaco V McVicar ad aother 7 Jauary 1984 QBD Departmet of Health 2001 Good Practice i Coset Implemetatio Guide: coset to examiatio or treatmet Lodo, DH Departmet of Health ad Social Care ad Public Safety Norther Irelad 2003 Good Practice i Coset to Examiatio, Treatmet or Care Belfast DHSSPS Departmet of Health 2006 Records Maagemet: NHS code of practice. Part 1 Lodo, DH Departmet of Health 2009 Records Maagemet: NHS code of practice. Part 2 Lodo, DH Dimod B 2008 Legal Aspects of Nursig 5th Editio Harlow, Pearso Educatio Limited Health Professios Coucil 2008 Stadards of Coduct, Performace ad Ethics Lodo, HPC Her Majesty s Statioery Office 1987 Cosumer Protectio Act (Commecemet No 1) Norwich, The Statioery Office Marti A, Hids C, Felix M 1999 Documetatio practices of urses i log term care Joural of Advaced Nursig Natioal Health Service Litigatio Authority 2010 Report ad Accouts Lodo, NHSLA Available from: 890C-42C0FC16D4D6/0/NHSLAAualReport adaccouts2010.pdf (Accessed November 2010) Natioal Patiet Safety Agecy 2009 Safer Surgery Checklist Lodo, NPSA Available from: /surgery/?etryid45=59860 (Accessed November 2010) Nursig ad Midwifery Coucil 2008 The Code: stadards for coduct performace ad ethics for urses ad midwives Lodo, NMC Nursig ad Midwifery Coucil 2009 Record keepig Guidace for Nurses ad Midwives Lodo, NMC Scottish Executive2008 Records Maagemet: NHS code of practice (Scotlad) Ediburgh, SE Scottish Executive Health Departmet 2006 A Good Practice Guide o Coset for Health Professioals i Scotlad Ediburgh, SEHD Scottish Patiet Safety Programme 2008 Perioperative Maagemet Driver Diagram ad Chage Package Ediburgh the Istitute for Healthcare Improvemet Available from: os/perioperativecaredriverdiagram.pdf (Accessed November 2010) Taylor H 2003 A exploratio of the factors that affect urses record keepig British Joural of Nursig 12 (12) Wood S 2010 Effective record-keepig Practice Nurse 39 (3) Further readig Associatio of Aaesthetists of Great Britai ad Irelad 2007 Recommedatios for Stadards of Moitorig Durig Aaesthesia ad Recovery Lodo, AAGBI Dimod B 2003 Legal cocers i tissue viability ad woud healig Nursig Stadard 17 (23) Griffiths P, Debbage S, Smith A 2007 A comprehesive audit of ursig record keepig practice British Joural of Nursig 16 (21) Healy K, Hegarty J, Keatig G, Laders F, Leopold S, O Gorma F 2008 The chage experiece: how we updated our perioperative documetatio Joural of Perioperative Practice 18 (4) Pirie S 2006 The eed for accurate records Joural of Perioperative Practice 16 (1) Rodde C 2002 Record keepig: developig good practice Nursig Stadard 17 (1) Starr L 2009 Record keepig essetial Australia Nursig Joural 16 (9) 19 Taer J, Timmos S 1999 The implicatios of the data protectio acts for theatre urses British Joural of Theatre Nursig 9 (8) About the author Susa Pirie RGN, MA Health Care Ethics ad Law Practice Educator (Theatres), Surrey ad Sussex Healthcare NHS Trust No competig iterests declared Members ca search all issues of the BJPN/JPP published sice 1998 ad dowload articles free of charge at Access is also available to o-members who pay a small fee for each article dowload. Jauary 2011 / Volume 21 / Issue 1 / ISSN

7 Disclaimer The views expressed i articles published by the Associatio for Perioperative Practice are those of the writers ad do ot ecessarily reflect the policy, opiios or beliefs of AfPP. Mauscripts submitted to the editor for cosideratio must be the origial work of the author(s) The Associatio for Perioperative Practice All legal ad moral rights reserved. The Associatio for Perioperative Practice Daisy Ayris House 6 Grove Park Court Harrogate HG1 4DP Uited Kigdom [email protected] Telephoe: Fax: