The NMC, Nursing and Midwifery Council is the regulator for England, Wales, Scotland, Northern Ireland and the Islands. Since 1983, the NMC’s main role is to oversee and deal with professional misconduct complaints and to maintain, monitor and record the quality of students, nurses and midwives. This essay briefly discusses one of the four principles of the Nursing and Midwifery Council (2008), a guidance for nurse’s, midwives and the importance of good record keeping within the health care setting.
Good record keeping is an important part of a nurse’s role in the health care setting, and is as important as hands on clinical skills in maintaining patient’s safety. The NMC states that nurses and midwives should keep clear and accurate records of the discussions you have, the assessments you make, the treatment and medicine you give, and how effective these have been, and also, records should be completed as soon as possible after an event has occurred. Records must not be tampered with in any way and these records or entries must be clearly and legibly signed, dated and timed.
The entries made electronically must be clearly attributable to you, ensuring that all records are kept securely (NMC 2008). When a patient first comes into the health care setting a record or care plan regarding any ongoing treatment, assessment or reviews should be compiled so that other multidisciplinary teams can be involved in a patient’s care. When making entries, mistakes may be made and attempts to erase using correction fluid is not permitted. Instead a line should be put through the error, and then clearly signed and dated by the person entering the notes.
Having the correct and up to date information regarding a patient is vital to the health, well being and safety of the patient and can play a huge role in identifying any changes in a patients condition. Updating and completing records as soon as possible after an event has occurred is vital in keeping patient notes fully updated. Any observations, treatment or assessments made must be documented. In a report by The Daily Mail, 27th July 2012, registered nurse, Mr Nsengiyaremye, employed at Sussex Orthapaedic NHS, failed to carry out and record hourly observations on an elderly patient recovering from a hip operation.
His misconduct highlighted that his lack of record keeping and care led to the patient suffering a stroke eight hours before he had noticed any changes to her condition. Nsengiyaremye admitted all the charges against him, including not making a record of his care of the patient until he was ordered to more than 10 hours after his shift had finished. He was also found to have not made vital records of a patient’s fluid levels during the shift (http://www. dailymail. co. uk/health/article-2179832).
Keeping clear and accurate records is an important skill in order to maintain good communication between care staff regarding the needs of a patient. The care professionals involved in the care of a patient may never meet and as a result rely heavily on a patients records or notes to inform them of the patients health care needs. The guidelines for good record keeping helps nurses maintain good record keeping skills and is important if any legal issues arise surrounding the care, treatment or medical condition of a patient.