Record keeping is an integral part of community nursing practice and there is an obligation placed upon the community nurse to record good, clear and accurate information about their patients (Royal College of Nursing, 2023). NHS England (2023) also affirms that nursing and midwifery practice is ‘supported by good documentation that supports professional decision making and care’. However, record keeping can be challenging, especially in busy clinical environments and if you are a community nurse with a large caseload, record keeping can often be seen as a burdensome extra. Nevertheless, from a legal perspective, a general defence of being busy is not an acceptable one (McCormack v Redpath Brown [1961]). This article aims to illustrate the importance of record keeping from both a legal and professional perspective.
This obligation to provide good documentation generally derives from our contract of employment (Griffith and Dowie, 2019). However, there is also a need to be able to evidence the care and treatment undertaken by the community nurse. Records can take various forms; these include written notes, electronic and paper, email, care plans, video recordings and photographs or anything where a patient/client's care has been recorded by the community nurse. Failure to provide evidence of care via record keeping will place the community nurse at risk of being unable to su ciently defend their practice, either at a disciplinary hearing or a court of law. As reiterated by Stevens and Pickering (2010), if a complaint is made against you, your record of care is often the only proof to show that you had met your duty of care to the patient. In the case of Saunders v Leeds Western Health Authority [1993], a normally t 4-year-old girl experienced a cardiac arrest while in the operating theatre and consequently, suffered brain damage, blindness and quadriplegia. The theatre sta claimed that her pulse had stopped abruptly; yet, there was no evidence in the records of this claim. Normally for negligence to be found proven, a direct causational link needs to be established (Herring, 2018). However, in this case, the court took the view that it is not normal for a t 4-year-old girl to experience a cardiac arrest if appropriate protocols are followed, and that there was a lack of evidence from the records in providing a narrative to why the cardiac arrest occurred. The court was of the opinion that the practitioners were liable for the harm caused.
In the case of Mariott v West Midland Regional Health Authority [1999], a GP did not keep complete and comprehensive notes in relation to the care of Mr Marriot. The GP had stated that there were no neurological abnormalities. Later, Mr Marriot was found to have had an epidural haematoma and intercranial bleeding. The GP was held liable for the harm sustained by Mr Marriott, as he was unable to recall what was discussed with the patient as a result of his incomplete notes. In contrast, in the case of McLennan v Newcastle Health Authority [1992], a claimant alleged that a surgeon had not disclosed all the risks of treatment; yet, the written records kept by the surgeon indicated that upon the balance of probabilities, the risks had been disclosed to the patient. These cases help illustrate that the law is more likely than not to hold a community nurse to be liable if there is no documented evidence of the care provided, or if the record of care is incomplete. As a community nurse, it is essential you keep detailed and accurate written records of any care provided to limit your own liability, as well as to ensure safe ongoing care to patients.
Medical record keeping is also governed by the UK Data Protection Act 2018. This Act places an obligation upon community nurses to keep records safe and secure, and sharing of records can only be undertaken if in connection with the care of the patient. Any inappropriate sharing or an unacceptable breach of confidence that may arise due to poorly stored records may result in severe penalties from the Information Commissioner's Office, as well as potential disciplinary and regulatory action. The sharing of information, outside the care and treatment of the patient, must be consented to by the patient before being shared. Ensuring strong passwords are used for computer-based records, and ensuring paper-based records are stored in a secure area, will mitigate against careless breaches of confidentiality. In relation to safeguarding, it is permissible to share records without necessarily needing consent from the patient with appropriate professionals, such as social workers, or the police. However, this would be under exceptional circumstances where there are sufficient and reasonable indications that the patient, or other members of the public, would be at serious risk of harm if the disclosure was not made. A court can also demand to see records of patients for evidential purposes (Griffiths and Dowie, 2019).
Good record keeping provides evidence that the community nurse has delivered good-quality care (Stevens and Pickering, 2010). However, to illustrate this good quality of care, the community nurse needs to ensure records are clear, eligible and fact based. The use of speculation should be avoided; for example, instead of stating, ‘I think the patient might be fiddling with her bandages’, it would be better to phrase it as, ‘the patient's bandages were at the base of her ankle, and she was unable to provide an explanation as to why this happened’. Likewise, opinion should generally be avoided, so the statement, ‘I think the patient is short of breath’, should be written as the patient presented with difficulties in breathing. If an opinion is required, clearly state that the entry is being made in your professional opinion; for example, ‘it is in my professional opinion that the patient presents with a venous leg ulcer, a doppler assessment will be carried out later to confirm diagnosis’. Records should also be written in a manner that the patient would be able to understand the record, so avoiding unnecessary jargon is recommended. It is recommended that the community nurse completes the record with the involvement of the patient to allow for patient-centred care, paving the way for future collaboration and co-production with the patient in their own care. Records also need to be completed timely, to ensure a contemporaneous narrative is recorded. Any errors within the record needs to be highlighted, rather than erased, in order to show transparency. The commuity nurse always needs to be mindful that any investigation in relation to alleged poor patient care may be initiated several years after the provided care, so having a detailed record will help the nurse to recall events at any investigation/regulatory hearing or if the notes are presented at a court of law.
Good record keeping will also include:
- The full name of the author of the record
- The care and treatment provided
- Where a health concern/problem has been identified, what action or referral the community nurse has taken to ensure the concern is being further examined and monitored.
For example, a community nurse writes in the patient's notes that the patient has a grade 4 pressure ulcer on their left buttock, but no further details. While this might be clear, the record is incomplete unless the community nurse also records what immediate actions they performed to alleviate the issue. This can include a referral to the tissue viability nurse, as well as arranging for an appropriate pressure relieving mattress to be delivered to the patient's home.
The community nurse needs to always have in contemplation that anything that makes reference to a patient can be used as evidence. Under the common law (Donoghue vs Stevenson [1932]) the community nurse has a duty of care to provide clear and factual records, as otherwise, the care of a patient may be compromised. The case of Donoghue includes the test of foreseeability – if as a community nurse you could foresee that by not completing a timely record outlining the care of your patient, this may lead to serious harm.
There is also a professional duty to ensure record keeping is of a high standard (NMC Code, 2018). Any falsification of records (for example, making up the blood pressure of a patient) or poorly written records could lead to patient safety becoming compromised. This might be viewed as potential negligence, as well as potentially leading to a criminal conviction against the community nurse, or a civil action against the employer for the actions or inactions of the community nurse.
In conclusion, record keeping is an essential part of everyday practice and should not be seen as an optional extra. The law is clear that if there are limited or no records outlining the care of your patients, you will not have a sufficient defence to your practice. The NMC (2018) also outlines the importance of record keeping within its code of practice; any breach of the code may result in the community nurse being referred to the regulator. If there are significant challenges in completing records in a timely manner, it is essential that the nurse refers to their line manager or other senior colleagues to seek further support. The old maxim, that if it is not written down, it has not been done (Griffith and Dowie, 2019) remains an important consideration for any healthcare practitioner.