Principles of record-keeping
The overall principles of record-keeping, whether you are writing by hand or making entries to electronic systems, can be summed up by saying that anything you write or enter must be honest, accurate and non-offensive and must not breach patient confidentiality. If you follow these four principles, your contribution to record-keeping will be valuable.
More specifically, you should always try to ensure that you:
- handwrite legibly and key-in competently to computer systems
- sign all your entries
- make sure your entries are dated and timed as close to the actual time of the events as possible
- record events accurately and clearly – remember that the patient/client may wish to see the record at some point, so make sure you write in language that he or she will understand
- focus on facts, not speculation
- avoid unnecessary abbreviations – as you’ll find, the health care system uses many abbreviations, but not all workplaces use the same definitions: for instance, ‘DNA’ means ‘deoxyribonucleic acid’ in some places, but ‘Did Not Attend’ (meaning a patient/client who does not show up for an appointment) in others – avoid abbreviations if you can!
- record how the patient/client is contributing to his or her care, and quote anything he or she has said that you think might be significant
- do not change or alter anything someone else has written, or change anything you have written previously; if you do need to amend something you have written, make sure you draw a clear line through it and sign and date the changes
- never write anything about a patient/client or colleague that is insulting or derogatory.
When you’re writing, always follow the principles described in the section written communication and remember, if you find something you feel is significant when you are working with a patient/client, your first duty is to report it to the registered nurse in charge before you would consider writing it in the patient’s/client’s record. Always report first, record later.