Central to the nursing practice is the collection and recording of patient information. Documentation is the single process that unites and outlines all the relevant and crucial information, activities, progress, observations and everything that affects the patient and his or her therapeutic relationship with the nurse and indeed the healthcare team. The Nursing and Midwifery Board of Ireland (NMBI) is the statutory body of nurses in Ireland. NMBI oversees the nursing practice ensuring that nurses deliver safe and competent care to the public (NMBI, 2014).
Documentation and good record management is recognised by the HSE to benefit service users, clinicians and all stakeholders and ultimately improve patient outcomes (HIQA, 2018). High-quality information underpins the delivery of high-quality evidence based safe healthcare for service users, and many other key service deliverables (HIQA, 2012).The writer wishes to discuss the importance of good documentation and explore evidences of how poor record management can affect patient care, the nurse and the healthcare organisation. The Importance of Recording Clinical PracticeDocumentation plays various roles in all aspect of healthcare.
From the moment a patient makes contact with a healthcare institution, recording of information is almost instantaneous. With the involvement of two or more members of the healthcare team, essential information is being recorded, added, shared and passed on to others. Patient record is at the centre of the assessment, planning, intervention and review of the patient care and condition. To keep the system effective and efficient, the HSE and NMBI look after the different aspects of the service, which includes documentation, and seeks evidence of the quality of the practice.
Different authors and researchers suggest several reasons why recording clinical practice is important. The most common and primary reasons are discussed here in detail.Promotes patient safetyThe patient is the heart of the healthcare service. It is imperative that all the principles and goals of the nursing practice must revolve around the needs and expectations of the patient. The role of NMBI is to protect public (patient) health and safety by setting standards of practice for nurses and midwives (NMBI, 2015). The principle of collaboration, team-working, communication and documentation stresses that effective and consistent documentation is an integral part of the nurse’s practice and a reflection of the standard of an individual’s professional practice, and whether he or she is providing a safe, quality care to the patient or not (NMBI, 2014, pp. 26-28).In the HIPE Report published on October 2018, the Health Information and Quality Authority (HIQA) acknowledges that safe, reliable healthcare is reliant on the access to, and the use of, good quality information. To demonstrate the relation between documentation and patient mortality, Collins et al. (2013) investigated 1,500 acute care patients, and of those, 145 had had a cardiac arrest. Their findings showed that patients who had increased optional documentation of vital signs and comments experienced significantly higher rates of mortality. Provides evidence of quality patient care and evidence-based decision makingNMBI’s Guidelines for Recording Clinical Practice (2015), states that maintaining good record keeping gives documentary evidence of the delivery of quality patient care. Taylor et al. (2018) suggests that the patient record is the only legal document that details the nurse’s interactions with the patient and is the nurse’s best defence in case of any litigation (p.355). There are also some instances where the care provided by nurses are not evident because of the failure to describe the moment of care that can explain the effectiveness of a certain intervention (Moorehead, 2006, p. 174).In the Nursing and Midwifery Quality Care-Metrics Project Update, a presentation by White, documentation is a recurrent criterion in the core set of metrics for measurement and monitoring standards of care. Nursing metrics is a method which uses indicators and is used to measure the outcomes of nursing and the quality of patient experience (Foulkes, 2011). A personal experience during a previous clinical placement in Ballina Community Mental Health clearly exemplified how nursing metrics guide the individual and collective efforts of nurses in providing quality care to service users. Facilitates communication between patient, family and the healthcare teamAccording to the NMBI, good quality documentation facilitates communication between the patient, the family and all members of the healthcare team (NMBI, 2015).Nurses, in most healthcare settings, work within a multidisciplinary team (MDT). It must be borne in mind that, on most occasions, the MDT do not work with the patient all at the same time. This suggests that documentation is an essential tool in the continuity of patient care. It is the constant communication tool that allows vital patient information to be passed on from one member to another. Legal implicationsClinical records of patients can be used in the courts of law since they are deemed to be legal documents. Whatever has been documented during the delivery of care are the only written evidence that may explain the details of the patient condition and the nature of care that was performed. Courts consider acts not recorded are acts not done’. (Boyd, 2008) Over the years, a growing evidence in the increase of expenditure towards litigation and settlements can be seen in Ireland and the same has been reported in the UK and America.More than half a billion euro has been paid out on negligence claims brought against the Department of Health and the HSE since 2011In total, it left taxpayers with a bill for ‚503,353,000′ (McDonagh, 2017).The annual total pay-out involving HSE cases has more than doubled in recent years The total pay-out was ‚139 million. This averages at ‚172,475 a claim’ (Hutton, 2018). As at 31 March 2016, NHS LA estimates that it has potential liabilities of Ј56.4 billion, of which Ј56 billion relate to clinical negligence claims’ (NHS LA, 2016a: 2. Tingle, 2017)P. Duclos-Miller discussed a case of miscommunication which resulted in the failure to make a follow up appointment for a mother of a baby with significant birth defects as detected in the pre-natal scan. Nurses played a significant role in this case, as the unfortunate outcome was related to ineffective communication within the team. Regardless of the short life expectancy, the court awarded the mother $12 million. (Legal Eagle Eye Newsletter, 2015) (Patricia A., 2016, p. 2)Protect the integrity of nursing practiceNurses offer a valuable contribution to the healthcare service, but this does not shield them from committing errors in practice and therefore they are not immune to litigation and review. To protect the value and integrity of the nursing practice, NMBI sets out the Code of Ethics and Guidance for Recording Clinical Practice to guide nurses in their practice. A nurse whose practice is not in line with this code is liable to litigation and sanctions by the appropriate committees. The NMBI website publishes findings and decisions on complaints relating to individual nurse’s fitness to practice cases. Here are some examples relating to poor documentation leading to serious sanctions that affected the capacity of the nurses to further practice nursing. CASE No. 1Findings and Decisions Following Fitness to Practise Committee Inquiries (Nurses Act, 1985) On or about 8th August 2011amended Ms. A’s nursing recordswithout noting in the nursing records that this was a retrospective addition and/or when same was in breach of the Guidelines on Recording Clinical Practice in the Adult Nursing Services of Hospital X (2010); On or about the 20th October, 2011 failed to record in Ms. H’s nursing notesthat he did not administer her prescribed 12pm and 2pm medications to her until 4pm and/or when same was in breach of the policy on Medication Management at the point of care in Adult Services in Hospital X (2010); On or about 7th September 2011, failed to record in Ms. D’s nursing notesthat the patient refused to allow you to inspect the lumbar puncture site; Sanction: Pursuant to Section 39(1) of the Nurses Act, 1985, Mr. Y’s name was erased from the Register of nurses and midwives confirmed by the High Court on 26th August 2015 (NMBI, 2016).Case No. 2Findings and Decisions Following Fitness to Practise Committee Inquiries (Nurses Act, 1985) Failed to ensure that one or more of the following records were maintained adequately, and/or at all: Care Plans for Residents (as regards the adequacy of the records maintained); Accounts of Residents’ Personal Property and Possessions; and Directory of Residents; Sanction: Pursuant to Section 39(1) of the Nurses Act, 1985, Ms Z’s name was erased from the Register of nurses and midwivesconfirmed by the High Court on 18th April 2016. (NMBI, 2016)No matter how skilled a nurse you are, poor nursing documentation will undermine your credibility if you’re ever involved in a lawsuit (Austin, 2010, Duclos-Miller 2016, p2).Furthermore, Taylor et al. (2008) outlines the purposes that the patient records may serve- as communication with other healthcare professionals, recording of diagnostic and therapeutic orders, care planning, quality-of-care reviewing, research, decision analysis, education, legal documentation, reimbursement, and historical documentation (pp. 360-364).CONCLUSIONRecording clinical practice or documentation is a legal obligation and an essential requirement in NMBI’s of the Code of Ethics for nurses. Documentation is a tool which facilitates communication between the patient, family and the healthcare team. It is the evidence of the quality of the nursing care provided to the patient thereby providing a legal proof in cases of litigation or administrative review. The cases presented in this paper clearly demonstrates the benefits of documentation in relation to patient safety and the implications of poor documentation on the practice of the nurse and on a much broader scale, on the finances of the organisation. Documentation clearly benefits all stakeholders.