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					Guideline: C5
Patient Documentation
Purpose of the Guideline

The introduction to the Nursing and Midwifery Practices Manual outlines the purpose of all
Nursing and Midwifery Practice guidelines. In essence, the guidelines are designed to
provide staff with a framework for safe, research based nursing and midwifery practice,
whilst promoting individual patient care, and facilitating the exercise of professional nursing
judgment and critical thinking.
This guideline outlines good practice in relation to nursing documentation and forms the
basis from which audits of nursing documentation are carried out.

Contents
  Introduction
  Recommendations and procedures
  Nursing Records Only
  Accountability Record
  Signature Record
  Patient Profile
  Nursing Assessment
  Communication Sheet
  Care Plans
  Evaluation
  Other documentation entries
  Legal Aspects
  References
  Practice Guideline Audit Tool
  Appendix 1: Approved Abbreviations to be used In Trustwide Nursing/Midwifery
  Documentation
  Development of the guideline

Introduction
Patient documentation is an integral part of nursing and midwifery practice; an essential tool
to aid the care process and as such is not a separate optional activity from the provision of
care but one which happens alongside direct care delivery.
High standards of clinical care, continuity of care and improved communication between
health care team members is promoted through good record keeping which provides “an
accurate account of treatment and care planning and delivery”.
High standard documentation reflects the standard of professional practice and is a mark of
a skilled and safe practitioner, (NMC 2002)

Recommendations and procedures
    All records must be legible and permanent in black ink
    All entries must be factual, consistent and accurate, clear and unambiguous
    All documentation will be dated, timed and signed/countersigned by a registered
     nurse
    A record of signatures is to be kept in the documentation, or names printed after
     each signature entry
    All entries will be made as soon as possible after an event/activity, to provide current
     information in relation to sequence of events, factors observed and response to
     care/treatment. Full signatures should be used for major events
    Any alterations/errors will be crossed out with a single line, signed, dated and timed
    Any additions to existing entries must be individually signed, dated and signed
      Abbreviations, jargon, meaningless phrases and irrelevant speculation and offensive
       subjective statements must be avoided (NMC 2002). Only approved abbreviations
       may be included in nursing documentation (appendix 1)
      Documented records should, wherever possible be written with the involvement of
       the patient/client and in terms that they will be able to understand
      Patient consent/agreement should be obtained to keep all nursing documentation at
       the bedside. If consent is withheld an alternative could be inside the patients locker
      The initial admission assessment and care plan will be completed within 24 hours of
       admission
      All documentation will have a written response in every section, if a section is not
       applicable “n/a” must be used
      Ongoing assessment, planning and evaluation of care will be reviewed at least once
       in 24 hours, and updated as appropriate

Nursing Records Only
Admission Front Sheet:
The front sheet must be commenced promptly on admission
Patient addressograph labels must be used (as soon as available + the details checked for
accuracy)
Preferred name (manner of verbal address) must be identified
Document whether the patient consents to information being shared with family/carers
“Reason for Admission” should represent the patients understanding for admission
“Medical Diagnosis” should have the confirmed diagnosis entered as soon as available (this
may not be completed on admission)
“Key Details” should include any details that are not covered on the front sheet but the
nursing staff consider pertinent for good communication (this may include resuscitation
status, social circumstances, allergies, medications etc.

Accountability Record:
    This must be completed by the registered nurse responsible for the patients care
     each shift
    If the care given has not changed during the shift, the documentation is up to date
     and has been reviewed then only the accountability record needs to be signed
   
Signature Record:
    All staff recording any information in the nursing documentation must ensure they
      have completed an entry in the signature record. This applies to all grades of staff
   
Patient Profile:
Care plan summary:
    Each problem identified in the patients care plan should be entered and dated in the
       care plan summary – primarily as an aide memoir in the hand over of patient details
    Where care plans and evaluation entries are separate the care plans must be
       numbered, and corresponding evaluation entries numbered accordingly
    Unless stated otherwise in the patient profile or relevant care plans, all patients
       should be considered as independent and self caring in their activities of daily living
       (ADL’s)

Specimens/Investigations:
    This section should be completed for all specimens/investigations
    Ward urinalysis is to be documented on the TPR chart only

Nursing Assessment:
      The initial admission assessment and care plan will be completed within 24 hours of
       admission to hospital by a registered nurse (or student of nursing countersigned by
       the registered nurse)
      The nursing assessment should be completed on the patients admission to the ward
       and again upon any transfer from another ward/department
      Nursing staff receiving patients from the Emergency/Medical Admissions Units will
       continue the nursing assessment sheet commenced in those areas
      Risk assessments – Nutrition Score, Waterlow Score and Moving and Handling,
       should be incorporated into the nursing assessment process
      On admission every patient should be assessed using the ADL’s as a guide to
       identify any needs/problems

The following list outlines as a guide the areas of focus in assessment using ADL’s
    Breathing
           o respiratory effort, colour, cough, wheezes, smoking, chest care
    Communication
           o confusion, orientation to time & place, hearing problems, eyesight,
                speech/language problems
    Cultural Needs/Religion
           o patient religion must be recorded whether practising or not, religious/cultural
                preferences. Whether or not referral to chaplain required. (Paediatrics –
                whether baptised or not)
    Diet/Fluids
           o dietary needs, level of assistance required, mouth condition, denture wearer,
                type of diet, alcohol intake
    Elimination
           o level of assistance required, problems with bowels/urine, frequency of
                bowels/urine
    Emotional Needs/Body Image
           o exuality, effects of hospitalisation or treatment, anxiety status, mood, recent
                bereavement
    Pain/Discomfort
           o coping mechanisms, location of/type of pain, pain score
    Personal Hygiene
           o level of assistance required, skin status, personal preferences
    Mobility/Safety
           o level of assistance required, use of aids, recent falls, safety bed rails required
    Rest/Sleep
           o sleep pattern, bedtime routine, night sedation
    Work/Play
           o occupation/previous occupation, hobbies/pastimes, social activities
    Other
           o anything else ascertained during assessment but not applicable in other
                assessment sections but relevant to patients care

Communication Sheet:
   This is used for progress/communication by the multi professional team. It is not the
    nursing evaluation of care given

Care Plans:
    The initial admission care plan should be completed within 24 hours of admission to
      hospital
      Any care plans written by students of nursing must be countersigned by a registered
       nurse
      Care plans should specify the number of nurses required for activities, and identify
       the level of help required by the patient
      Where care plans and evaluation entries are separate the care plans will be
       numbered, and the corresponding evaluation entries numbered accordingly
      Resolved care plans will be crossed through with a single diagonal line, dated, timed
       and signed stating clearly “resolved”
      Care plans should provide a clear overview of the nursing care needs of the
       individual patient

Evaluation:
In general, the evaluation should reflect the patient response to care delivered
All entries should be dated, timed, signed and legible. Where evaluation is separate to care
plans, entries must be numbered to correspond with the number of the care plan

Other documentation entries:
All baseline observations are to be recorded on the TPR/Observation chart only.
Admission baseline observations should have “on admission” clearly stated on the
TPR/Observation chart
Ward urinalysis, weight and bowels should be recorded on the TPR/Observation chart
Discharge Health Assessment Form – refer to practice guideline C1 Discharge Health
Assessment: Basic Principles
Some wards will collect information specific and pertinent to them. This information should
be recorded in “Key Details” on admission front sheet

Legal Aspects:
Patient records may be called in evidence before a court of law, by the Health Service
Commissioner or at local level to investigate a complaint.
As a registered practitioner you have a professional and legal duty of care; your record
keeping should demonstrate:
     A full account of your assessment, the care planned and provided
     Relevant information about the patients’ condition at any given time and the
        measures taken to respond to their needs
     Evidence that the duty of care has been understood and honoured, with all
        reasonable steps taken, actions or omissions having not compromised patient safety
     A record of any continuing care arrangements made
Professional judgement on the frequency of entries will exist, reflecting the circumstances
and complexity of problems and needs specific to the patient concerned.

References:
Nursing and Midwifery Council (2002) Guidelines for records and record keeping. NMC:
London.

Practice Guideline Audit Tool
This guideline does not have an audit tool attached as there is a comprehensive a
documentation audit tool contained within the West Suffolk Hospitals nursing quality
assurance package.
Appendix 1: Approved Abbreviations to be used In Trustwide Nursing/Midwifery
Documentation
This list of approved abbreviations is not an exhaustive one. Each speciality may compile a
list of specific abbreviations used within their speciality for approval by the Nursing Practices
Steering Group (see appendix 2)
   ABG’s          Arterial blood gases             MRI             Magnetic Resonance Imaging
   ADL’s          Activities of Daily Living       MRSA           Methicillin resistant
   AF              Atrial Fibrillation             staphylococcus aureus
   BD             Twice daily                      MSU             Midstream specimen of urine
   BNO             Bowels not open                 N/A            Not applicable
   BP              Blood pressure                  NAD            Nothing abnormal detected
   BWO             Bladder washout                 NAI            Non accidental injury
   Ca              Cancer                          NBM            Nil by mouth
   CABG           Coronary artery bypass graft     NG             Nasogastric
   CCF              Congestive cardiac failure     NOF             Neck of femur
   CD’s            Controlled drugs                O/A            On admission/arrival
   c/o             Complaining of                  OPA             Outpatient appointment
   COPD            Chronic obstructive             OT              Occupational Therapy
   pulmonary        disease                        O2              Oxygen
   CPN             Community psychiatric nurse     PCA            Patient controlled analgesia
   CPR             Cardiac pulmonary               PE              Pulmonary embolus
   resuscitation                                   PEG             Percutaneous enodscopic
   C&S             Culture and sensitivity         gastrostomy
   CSU             Catheter specimen of urine      Physio           Physiotherapy/ist
   CT              Computerised Tomography         PO              Per orally
   CVA             Cerebral vascular accident      POP             Plaster of Paris
   CVP             Central venous pressure         PR              Per rectum
   D&C            Dilatation and curretage         PRN             As required/necessary
   DNA            Did not attend                   PU’d            Passed urine
   DNAR           Do not attempt resuscitation     PUO             Pyrexia of unknown origin
   DOB             Date of birth                   PV              Per vagina
   DVT            Deep vein thrombosis             QDS             Four times daily
   D/W            Discussed with                   RIH            Right inguinal hernia
   DN             District nurse                   Rt. or R        Right
   ECG             Electrocardiograph              ROS             Removal of sutures
   EEG              Electro encephlogram           RTA            Road traffic accident
   ENT            Ear, nose and throat             SALT           Speech and Language Therapy
   GA             General anaesthetic              SaO2                Saturation of oxygen
   GCS              Glasgow coma scale             S/B             Seen by
   GI              Gastro-intestinal               sc              Subcutaneous
   GP               General practitioner            sl             Sublingually
   GTN             Glycerin trinitrate             SW              Social worker
   HV             Health Visitor                   TPN            Total parental nutrition
   HNPU           Has not passed urine             TPR             Temperature, pulse &
   IM             Intramuscular                    respiratory rate
   IV              Intravenous                     TDS             Three times daily
   IVI           Intravenous infusion              TIA            Transient ischaemic attack
   IVP            Intravenous pyelogram            TOP            Termination of pregnancy
   LA              Local anaesthetic               TTO’s           Drugs to take out
   LFT’s          Liver function tests             TURP            Transurethral resection of
   Lt or L        Left                             prostrate
   LVF             Left ventricular failure        TURBT          Transurethral resection of
   LIH            Left inguinal hernia             bladder tumour
   MDT            Multi disciplinary team          URTI           Upper respiratory tract infection
mg   Milligram               USS    Ultrasound scan
MI   Myocardial infarction   UTI   Urinary tract infection
ml   Millilitre              VF    Ventricular fibrillation
mm   Millimetre              Wt    Weight
Development of the guideline
Changes compared to previous document
These guidelines are similar in content to the previous document, but have been updated to
ensure that they comply with the latest NMC guidance.

Statement of clinical evidence and rationale
This guidance is based on national recommendations on records and record keeping
produced by the Nursing and Midwifery Council (the national regulatory body for nurses,
midwives and health visitors.

Contributors and peer review
This document has been circulated for comment to members of the Nursing and Midwifery
Practice and Policies Committee. In addition, the abbreviation list has been circulated for
comments to all ward sisters and operational managers in the Trust; changes were
discussed at the Nursing and Midwifery Practice and Policy Committeee and changes made
in response to those comments.

Distribution list/dissemination method
Distribution of paper copies will follow the Nursing Practices and Policies Committee’s
distribution list. The guideline will also be available on the Pink Book.

Document configuration information
 Author(s):              Jane Croker, Clinical Practice Facilitator
 Other contributors:     Ward sisters, Operational Service Managers, Members of Nursing
                         and Midwifery Practice and Policies Committee.
 Approved by:            Nursing and Midwifery Practice and Policies Committee.
 Issue no:               2
 File name:              C5
 Supercedes:             C5 (1997)
 Additional Information:

				
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