What constitutes a patient record?

The Nursing and Midwifery Council (NMC) are adamant that good record keeping is an integral component of safe and effective nursing care. In the context of children’s and young people’s nursing this constitutes any carer-related information about the physical or mental health of a named child or family member made on behalf of or by a health care professional:

• Handwritten notes including Post-it trigger notes (especially information given over the telephone)
  
• Emails
  
• Electronic monitor printouts
  
• Tape-recorded telephone conversations (as in 111 calls)
  
• Text messages.

The cost to the NHS of health care litigation in England is increasing and poor record-keeping is often cited: ‘if it was not recorded it never happened’. Hence, nurses should ensure that their record keeping is meticulous.

CIA mnemonic

The NMC policy is clear in highlighting the importance of nurses keeping records that are accurate and recorded in such a way as to ensure that their meaning is clear. All nurses have a professional and legal duty to keep records that meet the CIA mnemonic:

• Clear
  
• Intelligible
  
• Accurate.

Good CIA records are necessary to facilitate synchronous patient care, clinical audit, patient safety and patient decision making, and in promoting continuity of care across inter-professional and inter-agency boundaries. Importantly, CIA records show how patient decisions were made, and may be used in addressing complaints and subsequent legal processes.

Ensuring good record keeping

There are a number of important principles of good record keeping that nurses can use to help ensure that all their records meet the NMC requirements: