Good record-keeping - L'Infirmière Magazine n° 368 du 01/02/2016 | Espace Infirmier
 

L'infirmière Magazine n° 368 du 01/02/2016

 

FORMATION ANGLAIS

ÉMILIEN MOHSEN  

A resident nurse explains to a trainee nurse the importance of clear and accurante patient records.

Nurse : First of all, you must know that you have a professional and legal duty to keep records. You should thus allocate time for this documentation. Remember that without clear and accurate records for each patient, your handover to the next nursing team will be incomplete. Needless to say that this could affect the patient’s wellbeing ! A full account shows how careful, accurate and professional you are. Poorly written records can lead to doubts about the quality of your work. It can be even more serious.

Trainee : What do you mean ?

Nurse : Think of the legal aspect of record-keeping. In case of a patient’s complaint or any kind of legal proceedings, your nursing records are the only proof that you have fulfilled your duty of care to the patient. Poor record keeping can show some kind of negligence, even if you did provide the correct care. And this may lead to lose your right to practice. Do you see what I mean ?

Trainee : Yes, I think so. In short, the patient’s nursing record provides a clear account of the care planned and treatment given to the patient. It also ensures good communication as record-keeping shows that the information is correctly shared among the collegues. It also identifies problems that might have happened, and the actions taken to rectify them. But then what should go into a patient’s nursing record ?

Nurse : You should note down what nursing care the patient receives and the patient’s response to it. The records must show all relevant information about the patient at any stage. You should also indicate any other factor or event that may have affected the patient’s wellbeing.

Trainee : What could affect his wellbeing if he’s correctly taken care of ?

Nurse : It could be anything : unexpected noise, impromptu relatives’ visits, appointment for a scheduled surgery in the operation room…

Trainee : If we are unable to give a verbal handover to the next nursing team, what key elements should be written down in these records to set up continuing care of a patient ?

Nurse : You should ensure that the record begins with an identification sheet that contains the patient’s personal data: name, age, address, next of kin, carer, and so on. Date and sign each entry, giving your full name. Give the time, using the 24-hour clock system. Write in dark ink and never use a pencil as it may be erased or fade with time. On admission, record the patient’s visual acuity, blood pressure, pulse, temperature, and respiration, as well as the results of any tests. State the diagnosis clearly, but you should also indicate any other problem the patient is currently experiencing. Record all medication given to him and sign the prescription sheet. In case of surgery, ensure that the consent form is signed clearly by the patient and is included in the patient’s records. Include a nursing checklist to ensure the patient is prepared for any scheduled surgery. And finally note all plans made for the patient’s discharge.

VOCABULAIRE

Duty : tâche

Allocate time : allouer du temps

handover : transmission

Legal aspect : la part légale

Patient’s record : le dossier patient

Prescription sheet : ordonnance

Wellbeing : bien-être

Pulse : pouls

Scheduled : programmé

Common phrases

The patient records must be clear and accurate.

→ Le dossier patient doit être clair et précis.

Keeping good nursing records allows identifying problems and all the actions taken to rectify them.

→ La bonne tenue du dossier permet d’identifier les problèmes et toutes les actions prises pour y remédier.

Good record-keeping shows how careful and responsible a nurse is.

→ La bonne tenue du dossier atteste de la minutie et du professionnalisme d’une infirmière.

The nursing record is the only proof that you have fulfilled your duty of care.

→ Le dossier patient constitue la seule preuve que vos obligations ont été remplies.

You should note down what nursing care the patient receives.

→ Notez tous les actes de soins prodigués à un patient.

Record all medication given to the patient and sign the prescription sheet.

→ Notez les médicaments donnés au patient et signez l’ordonnance.