Care Planning Documentation and Daily Notes Writing

In the majority of homes I visit I come across, copious amounts of care plans and nursing/daily notes. 90% of these are not written as per NMC guidelines. Nurses, Managers, care coordinators, and care assistants are all to blame here. I come across abbreviations, numbers, jargon, personalised remarks. I get really frustrated and a bit bolshie regarding the care planning process. I see lovely care plans but they are backed up with really shoddy daily entries, that are meaningless or are still set in the dark ages. So rather than get frustrated anymore (the reason I started this blog) I have decided to give my two pence worth in writing for all to see.
Care Planning Documentation
Aims and objectives of my blog on care planning is to provide information on documentation and record keeping, To understand why records are kept also we will examine legal issues relating to record keeping and ‹to gain an understanding of the standards required for documentation.
‹The writing of the service user record is an integral role of the registered nurse, midwife & Healthcare Assistant. ‹The nursing/ care record is the written evidence of nursing/care practice, if it is accurate, timely and comprehensive, it reflects quality care.
The key principles for quality records are outlined in Nursing and Midwifery Council (NMC) guidelines (2009).
Why keep quality records?
Greater involvement of Service Users in making choices about care ‹
Service User centred care
Service Users having access to their own records ‹
Technology ‹
Clinical audit
‹Clinical negligence
Poor record keeping
Inappropriate remarks and ‹abbreviations ‹undermines Service User’s care it also ‹makes you vulnerable to legal and professional problems and can also increase your workload. ‹‹Vague comments such as – “reasonable”, “adequate” are not appropriate.
Guidelines for practice
‹Frequency of entries should be determined by professional judgement and local standards. ‹Records need to follow a logical sequence with clear milestones and goals. ‹Things that have not been done need to be documented as well as those that have.
‹Registered nurses are not professionally accountable for entries made by student nurses and healthcare assistants.
Service User records should: Be factual, consistent and accurate. They should ‹be written as soon as possible after an event has occurred. ‹ You should provide current information on the care and condition of the Service User, ‹ Dated, timed and signed with the signature printed alongside the first entry. ‹ The record should be written in terms the Service user can understand, and when possible with the involvement of the Service User. Not on any account must you include abbreviations, jargon, meaningless phrases, irrelevant speculation or offensive subject terms. ‹The care record should be readable on any photocopies- you should therefore write in black ink. ‹ Alterations must be crossed out with one line, dated and signed. Ensuring the original entry can still be read.
Do not mistake Assumption for Fact, ‹If you didn’t see it, hear it or do it, you don’t know it. For example, rather than “the service user fell out of bed,” write “I found the service user on the floor in a position consistent with a fall. ‹Record service user’s comments and requests and those of relatives ‹Use phrases such as “it was further reported that” write what the service user said they felt or perceived.
How much is enough?
Use your professional judgement. Ask yourself: if I were caring for this service user for the first time, what would I need to know?
Keep notes current and up to date. ‹In an emergency situation there is not always time to make notes at every step but it is vital to record information as soon as possible and by law within 24 hours.
Only write meaningful Statements Comments such as “resident slept well” or “as per care plan” are meaningless.
If you are suggesting changes in care, update the care plan accordingly and act on them; ‹Remember – if it isn’t in the notes, it didn’t happen Avoid abbreviations, Abbreviations in one place may not mean the same in another. For example, CNS can be central nervous system or clinical nurse specialist.
All staff – and the service user must be able to understand what is written.
Negligence & Law
Careful and accurate records may assist if you are defending claims of negligence ‹ It is important that you record the reason for decisions, as well as the actual intervention undertaken. ‹ To prove liability in negligence a claimant must establish 3 elements 1. The existence of a duty of care. 2. Breach of that duty of care and cause.
Damage or injury Limitation act 1980
A claim can be brought to court up to 3 years from which the injury occurred. Negligence is a term used by the legal profession to assess in any given situation, whether a person’s action or omissions have fallen below what is regarded by law as acceptable. The employing authority is vicariously liable for any negligence which may be committed by a healthcare professional in the course of their employment Legal proceedings. ‹The first thing they ask to see is the records. The Service User’s records are often the deciding factor in whether or not a legal case proceeds ‹If they find shoddy records, they assume shoddy practice and are more inclined to go ahead with a claim.
So it is important that you follow my blog to the letter you won't go far wrong.