Record keeping or documentation is an integral component of communication in today’s healthcare climate. It is essential that good practice in record keeping is upheld and that documentation is undertaken and maintained according to local policies and recommendations from the Nursing and Midwifery Council (NMC, 2010). Keeping accurate and thorough health records is part of providing the best care for the children, young people and their families. A health record collates information about the health condition of an individual recorded by health professionals in the multi-disciplinary team (MDT).

The Figure provides an overview of the main areas of good record keeping taken from the NMC (2010) guidelines.

Handwriting should be legible and all entries to records should be signed, dated with a time indicated. For written records, name and job title should be printed alongside the first entry. Records should be accurate, factual and the use of abbreviations, subjective judgements and jargon avoided. It is also important to ensure that important events about a patient are recorded in a timely fashion. The term ‘contemporaneous’ in relation to record keeping refers to information being written at the time of the event or as soon afterwards that is possible to provide a chronological and accurate record of events. This is vitally important as it captures the reality of the events within which care was delivered and can be used in evidence in any legal proceedings.

The language used should be easily understood by those in our care and all records should be readable when photocopied or scanned. Records should not be altered or destroyed without authorization.

Details of any assessments and reviews undertaken including documentation of future planned care should be undertaken for all children and families. Where appropriate, children and their families, should be involved in the record-keeping process regarding plans and decisions.

There are certain important elements of record keeping that must be considered:

Confidentiality: Nurses should be fully aware of the legal requirements and guidance regarding confidentiality, and again, ensure practice is in line with national and local policies. Discussions about those in our care should not take place where they might be overheard, and records, either paper or digital, should not be made available to others. Data protection policies must also be followed in line with this.

Access: Children and families in our care have a right to ask to see their own health records and they also can ask for their information to be withheld from you or other health professionals. This should be respected unless withholding such information would cause serious harm to that person or others. Records should not be accessed to find out personal information.

Disclosure: Information that can identify an individual must not be used or disclosed for purposes other than healthcare without the individual’s explicit consent unless the law requires it.

Information systems: Smartcards or passwords to access information systems must never be shared. Similarly, systems should not be left open to access by unauthorized persons. All systems should be used appropriately, particularly in relation to confidentiality.

Personal and professional knowledge and skills: Nurses have a duty, according to the NMC (2010) ‘to keep up to date with, and adhere to, relevant legislation, case law, and national and local policies relating to information and record keeping’. The ability to communicate effectively within teams is a crucial part of nursing practice. The way information is recorded is important since other members of the MDT will rely on records at key communication points, for example, at handover, referral and in shared care.

Record keeping in the form of care plans is an important part of holistic care so that all members of the MDT are aware of the individual care needs for children and families. The Figure summarizes the four important areas for record keeping and communication between health care professionals: assessment, planning of care, delivery of nursing care and evaluation of that care. These are the components of the nursing process; this, along with planning care, is the subject of Chapter 10.

Communication between nursing shifts is essential for safe and consistent care and the handover period is central to this. Clear documentation should be in place in order to hand over important information about the planned care for individual children and families. The Figure uses the SBAR mnemonic (Situation-Background-Assessment-Recommendations) to illustrate which elements can be recorded to hand over all the essential information to the subsequent shift.

Nurses have a professional role and responsibility to ensure accurate record keeping in line with their code of conduct. There are also important ethico-legal issues surrounding record keeping that nurses should be aware of. Patient records are legal documents and can be used in cases of litigation against a Trust to prove the events that occurred; therefore, it is vital that all care and outcomes are clearly documented throughout the stay in hospital or the care period. At times of conflict, accurate and objective documentation is essential. Finally, where consent is obtained from patients, be this from the child or the family, it must be recorded clearly in the health records.