Adey, Sofia, Liz

THE DATA PROTECTION Act 1998 defines aTHE DATA PROTECTION Act 1998 defines ahealth record as any electronic or paperhealth record as any electronic or paper

information recorded about a person for theinformation recorded about a person for thepurpose of managing his or her health care.purpose of managing his or her health care.

In 1992 Toms identified that nurses did notconsider record keeping a high priority activity,

and this remains an issue today. The annual reportof professional conduct produced by the NMC for

2002-2003 highlighted that issues regardingclinical practice, including failure to keep accurate

records, were the biggest category of offence,accounting for 30 per cent of all charges made(NMC 2003). Nurses continue to be removed

from the professional register for failing to keepaccurate records, which is an ongoing area of

concern.

NMC Records and Record NMC Records and Record Keeping, (2007)Keeping, (2007)

Be factual, consistent and accurate, written in a way that the Be factual, consistent and accurate, written in a way that the meaning is clear; meaning is clear;

Be recorded as soon as possible after an event has occurred, Be recorded as soon as possible after an event has occurred, providing current information on the care and condition of the providing current information on the care and condition of the patient / client. patient / client.

Be recorded clearly and in such a manner that the text cannot be Be recorded clearly and in such a manner that the text cannot be erased or deleted without a record of change.erased or deleted without a record of change.

Be recorded in such a manner that any justifiable alterations or Be recorded in such a manner that any justifiable alterations or additions are dated, timed and signed or clearly attributed to a additions are dated, timed and signed or clearly attributed to a named person in an identifiable role in such a way that the original named person in an identifiable role in such a way that the original entry can still be read clearly. entry can still be read clearly.

Be accurately dated, timed and signed, with the signature printed Be accurately dated, timed and signed, with the signature printed alongside the first entry where this is a written record, and alongside the first entry where this is a written record, and attributed to a named person in an identifiable role for electronic attributed to a named person in an identifiable role for electronic records. records.

Not include abbreviations, jargon, meaningless phrases, irrelevant Not include abbreviations, jargon, meaningless phrases, irrelevant speculation, offensive or subjective statements.speculation, offensive or subjective statements.

NMC Guidelines for the Administration of NMC Guidelines for the Administration of MedicinesMedicines

Accountable for your actions/omissions when administering medication – you must Accountable for your actions/omissions when administering medication – you must apply professional judgement and knowledge.apply professional judgement and knowledge.

PrinciplesPrinciples Know the therapeutic uses of the medicine to be administered.Know the therapeutic uses of the medicine to be administered. Identify the patient to whom the medicine is being administered.Identify the patient to whom the medicine is being administered. Awareness of patient’s care plan.Awareness of patient’s care plan. Consider dosage, method of administration, route and timing.Consider dosage, method of administration, route and timing. When supervising a student nurse in administration, clearly countersign the signature When supervising a student nurse in administration, clearly countersign the signature

of the student.of the student. It is unacceptable to prepare substances for injection in advance of their immediate It is unacceptable to prepare substances for injection in advance of their immediate

use.use. Do not administer medicines drawn up by another practitioner when not in their Do not administer medicines drawn up by another practitioner when not in their

presence.presence.Management of ErrorsManagement of Errors Must report immediately.Must report immediately. Require thorough and careful investigation – taking into account the context and Require thorough and careful investigation – taking into account the context and

circumstances.circumstances. Sensitive management and comprehensive assessment will be applied.Sensitive management and comprehensive assessment will be applied. NMC will consider whether the error is due to reckless or incompetent practice.NMC will consider whether the error is due to reckless or incompetent practice.

Accountability Advice Sheet (NMC, Accountability Advice Sheet (NMC, 2004).2004).

Nurses hold a position of responsibility and people rely on this. Nurses are Nurses hold a position of responsibility and people rely on this. Nurses are professionally accountable to: professionally accountable to:

-NMC.-NMC. -Employer.-Employer. -Law. -Law. -Patient. -Patient. ““As a professional, you are personally accountable for actions and As a professional, you are personally accountable for actions and

omissions in your practice and must always be able to justify your omissions in your practice and must always be able to justify your decisions.”decisions.”

Nurses must act in the best interest of the person in their care at all times. Nurses must act in the best interest of the person in their care at all times. If the nurse is delegating care they must delegate effectively and are If the nurse is delegating care they must delegate effectively and are

accountable for the appropriateness of the delegation. accountable for the appropriateness of the delegation. Nurses must;Nurses must; Establish that anyone they delegate to is able to carry out their instructions. Establish that anyone they delegate to is able to carry out their instructions. Confirm that the outcome of any delegated task meets required standards. Confirm that the outcome of any delegated task meets required standards. Make sure that everyone they are responsible for is supervised and Make sure that everyone they are responsible for is supervised and

supported. supported. Accountability is integral to professional practice. Accountability is integral to professional practice.

The Code: Standards of conduct, The Code: Standards of conduct, performance and ethics for nurses performance and ethics for nurses

and midwives (NMC, 2004).and midwives (NMC, 2004). Be open and honest, act with integrity and uphold the reputation of your profession. Be open and honest, act with integrity and uphold the reputation of your profession. Failure to comply with code may bring fitness to practice into question and endanger Failure to comply with code may bring fitness to practice into question and endanger

registration. registration. You must work with colleagues to monitor the quality of your work and maintain the You must work with colleagues to monitor the quality of your work and maintain the

safety of those in your care. safety of those in your care. Share information with your colleagues. Share information with your colleagues. You must facilitate students to develop their competence. You must facilitate students to develop their competence. Delegate effectively.Delegate effectively. You must establish that anyone you delegate to is able to carry out your instructions. You must establish that anyone you delegate to is able to carry out your instructions. You must confirm that the outcome of any delegated task meets required standards. You must confirm that the outcome of any delegated task meets required standards. You must make sure that everyone you are responsible for is supervised and supported. You must make sure that everyone you are responsible for is supervised and supported. Manage risk.Manage risk. You must act without delay if you believe that you may be putting someone at risk.You must act without delay if you believe that you may be putting someone at risk. Deal with problems.Deal with problems. You must act immediately to put matters right if someone in your care has suffered harm You must act immediately to put matters right if someone in your care has suffered harm

for any reason.for any reason. You must explain fully and promptly to the person affected what has happened and the You must explain fully and promptly to the person affected what has happened and the

likely effects. likely effects.

ReferencesReferences Data Protection Act (1998) The Home Office. The Stationery Office, Norwich. Nursing and Midwifery Council (NMC) (2007) Record Keeping, London. NMC (2008) The code; standards of conduct, performance and ethics for nurses and midwives, London. NMC (2004) Accountability advice sheet, London Professional Conduct Annual Report (2002-2003). NMC, London. www.hmso.gov.uk Toms EC (1992) Evaluating the quality of patient care in district nursing. Journal of Advanced Nursing.

17(12), pp1489-1495.