IMPORTANCE OF NURSING

CINICAL NOTES AND

RECORDS KEEPING

PRESENTED BY;
Capt; Min Min Aung
Nursing Officer
 OBJECTIVES
To ensure best practice in clinical
setting by competency
\to carry out any care and
to document the care.

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 LEGAL ISSUE

cover themselves

negative and defensive attitude can be faced

rather than providing right care

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 COMMUNICATION TOOL
• All practioners have information to make
appropriate clinical decision
• Rationale in implementing particular intervention
• Evaluation of care progress use nursing care
mode, reassess and planned interventions
( daily activities of living)
• Early detect eg. of risk as fall problems, pressure
ulcer, phlebitis in cannula

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 INVESTIGATION
• In serious incident or complaint, audit on to
establish what was wrong and led to incident
to preview the incident from recurring RCA
(Root-cause- analysis) (RCN, 2013)
• What happen, when, actions, why, who was
informed
• Difficult to establish solutions

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 NEGLIGENCE

Courts have to satisfy three main areas:

• The nurse had a duty of care to the patient;

• The nurse was negligent through actions or

omissions;
• caused the patient harm. (NMC, 2008)

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 ACCOUNTABILITY

• To adherence to the code of conduct

• To perform right standard for their role

• there are claims of negligence or criminal acts

(law); the patient and family. (NMC, 2008)

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 CONFIDENTIALITY 

• Nursing staff have duty to retain
confidential nature of patient records  at all 
times 
• Disclosure of any information held in patient 

records -serious offence

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 SUPPORTING INTEGRATED CARE

Good record keeping

• integral part of nursing and midwifery
practice -essential to provision of safe
and effective care
• comprehensive and concise record
• patient Centre of care, track clinical decision-
making and care goals
• protect clinicians against clinical negligence
claims
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Poor record-keeping
• workload, undermines patient care
• makes individuals vulnerable
• legal and professional problems
• Open to misinterpretation

• Devasting massage by use of abbreviation

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 COMMON PROBLEMS WITH
RECORD KEEPING
• Absence of clarity e.g. the meaning of ‘slept
well’ -not clear
• Failure to record action taken when problem-
identified, e.g. 'increasing pain' then no record
of action taken
• Missing information, e.g. administration of
drug not documented

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• Spelling mistakes, e.g. error in name resulting
in wrong diagnosis
• Inaccurate records, e.g. Changing dressing
or giving medication, when in fact patient
had not received recorded treatment (leading
to nurse being removed from Register)
• Failure to document conversations
• Failure to document care given
• Failure to document special needs

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• Failure to record telephone calls, e.g. on risk
of suicide
• Failures in communication between healthcare
professionals
• Too much jargon
• Patient identification, e.g. entry of
information on identity band, clinical
documentation and failure to transfer patient
details on continuation sheets

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 RECOMMENDATIONS FOR PATIENT
RECORDS
• Patient records should:
    - Be factual, consistent and accurate.
    - Be written as soon as possible after event
has occurred.
    - Provide current information on care and
condition of patient.
    - Dated, timed and signed with signature
printed alongside first entry.
    -
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 RECOMMENDATIONS FOR PATIENT
RECORDS
• Be written in terms patient can understand, and
when possible with involvement of patient.
• Not include abbreviations, jargon, meaningless
phrases, irrelevant offensive subject terms.
• Be readable on any photocopies - black ink is
preferable.
• Alterations must be crossed out with one line,
dated and signed, ensuring original entry can still
be read. (NMC, 2009)
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 Electronic records

• apply to computer and faxed records as they

do with all other records.

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 GUIDELINES
• Making continuity of care

• Provides evidence of services delivered in developed

countries
• Record should photocopy, scanned

• Should not falsify records

• Records must be accurate and written in such a way that

the meaning is clear (NMC 2009) (HPC 2008).
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• record must be dated (to include date/
month/ year), timed accurately and signed

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 HOW DO WE TRY PROPER RECORD
KEEPING
• To improve four skill in all staff according to
their level of education
• Verbally information of team leader must be
noted down
• All staff have to expect for electronic health
record (EHR)
• Minimizing time spent on documentation and
maximizing time for patient care

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 HOW DO WE TRY PROPER RECORD
KEEPING
• Narrative notes should be carry out speech
information and proof in sign-off with
promising result
• Dated, timed and signed with signature printed

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 CONCLUSION

Good record keeping

• enhances patient care
• Clear purposeful record
• Achieve best outcome of patient

• When creating health records, nurses should be aware

of the wider audience and uses of their records.

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 REFERENCES
• Nursing and Midwifery Council (2008), The
Code: Standards of Conduct, Performance and
Ethics for Nurses and Midwives. London:
www.nmc-uk.org/code
• Nursing and Midwifery Council (2009),
guidelines for records and record keeping
• Royal College of Nursing(2013), Delegating
Record-keeping and Countersigning Records
Guidance for Nursing Staff. London
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THANKS OF ALL
ANY QUESTIONS …..?