CHAPTER 7 Report writing: confidentiality of and access to patient records

Including e-records and incident reporting

Report writing

The writing of patient reports is an integral and important part of a nurse’s work. The patient’s records, particularly the written reports by health personnel that are incorporated into the record, should constitute an ongoing account of the patient’s healthcare experience. The written reports should provide an assessment of the patient’s progress for the medical and nursing staff concerned and, on the patient’s transition to their next stage of treatment, they provide a record of treatment given, progress made and a history for future consultation as required. In addition, a patient’s healthcare history and the accompanying records are used for teaching, quality and research purposes and, from time to time, a patient’s healthcare records will be required as evidence in court. When that situation arises, the health authority or the individual medical practitioner is served with a subpoena requiring them to produce the relevant records. A patient’s records can be used in civil and criminal proceedings in the following ways.

In civil proceedings against healthcare organisations or providers, more often than not, a patient’s record is used as evidence to support an allegation that a certain treatment was wrongly given or there was a failure to give a particular treatment. The patient’s record can also be used as supporting evidence of other matters that may be in dispute in civil proceedings — for example, that a particular injury occurred as a result of an accident and/or the circumstances in which it was alleged by the patient to have occurred.

In criminal proceedings, a patient’s record can be used as evidence that a complaint of assault and/or injury occurred and show the nature and extent of the injury. For example, in relation to a charge of sexual assault, it may be that the first place the victim came to for help was the accident and emergency department of a hospital. On arrival the victim would invariably give an account of events leading up to his or her presence at the hospital. In such a situation, the health professional’s record of the words used in relation to the complaint made and the injuries sustained may become important evidence in the criminal charge that may well follow.

For whatever purpose a patient’s records are required in legal proceedings, such records, including the nursing records, will be subject to close and careful scrutiny. It is important, therefore, that these records meet the standard expected of them, having regard for the purpose for which patients’ records are used.

Relevant considerations in writing reports

There is no specific format or outline for proper report writing. There are a number of different techniques or models of documentation which include: progress notes; various types of charting by exception, such as documentation of variance, and charting of clinical incidents; problem-oriented medical records; and more standardised formats, such as clinical or critical pathways, clinical algorithms and pre-designed clinical care plans. Although many organisations still use handwritten records, computerised systems are rapidly being introduced into our healthcare system at present, with some organisations using a combination of both. These electronic health records, or e-records as they are known, will be discussed in more detail later in this chapter.

However, certain points are common to all forms of records and should always be borne in mind. These can best be summarised as follows.

Reports should be accurate, brief and complete. Accuracy is obviously essential and it is important to distinguish between what is personally observed and what is related as part of a patient’s complaint of illness or injury — for example, the difference in the record between writing ‘patient assaulted by two men’ and ‘patient reported that he had been assaulted by two men’. Unless the assault was actually witnessed, the patient’s complaint of injury is clearly hearsay evidence and must be reported as such. ‘Brief and complete’ may sound like a contradiction in terms, but primarily what is important here is to avoid unnecessary verbosity. As part of ensuring the reports are complete, reference should always be made where a patient refuses any treatment or medication or acts in a manner contrary to healthcare advice. For example, it is a patient’s right to refuse their medication, as was discussed in Chapter 4, but it is important to document the refusal so that any adverse outcomes can be monitored and accounted for should they occur.

Reports should be legibly written. Incorrect interpretation of a person’s handwriting can lead and has led to many mistakes. Remember also, if unsure, always check. This problem will hopefully be overcome with the introduction of computerised records.

Reports should be objectively written. In the past there was a habit in nursing records of reporting about a patient in sweeping conclusive terms prefaced by the word ‘appears’. The use of the word ‘appears’ was apparently designed to qualify the conclusion made with a subjective value judgment — for example, the patient ‘appears’ to be drunk. Such a method of report writing is unacceptable. What is required is an objective, definite statement of fact. This critical distinction can best be summarised as follows: ‘Learn to record what you see, not what you think you see’. Three examples follow.

A simple rule to follow is only to write facts. That is, record what you heard, saw or did and provide as much specific clinical information as possible, such as measurements of clinical signs and results.

1. A statement such as the ‘patient appears to be drunk’ would be more accurately reported in the following, or similar, terms:

the patient is unsteady on his/her feet

the patient’s speech is slurred

the patient’s breath smells strongly of alcohol.

2. A statement such as the ‘patient appears to be shocked’ would be more accurately reported in the following, or similar, terms:

the patient is pale and sweating

the patient’s pulse rate and blood pressure are specified

the patient has peripheral cyanosis, or the patient’s fingers and toes are blue.

3. Another common problem nurses seek guidance on is how to report the patient’s sleep status, especially in the night duty reports. Justification for the use of the word ‘appears’ in this context seems to be that some qualification and/or protection is required in cases where the nurse has written ‘patient slept well’ but the next morning the patient reports that he or she didn’t sleep well at all. This can be difficult for nurses as, even if the patient had one unobserved period of wakefulness but was sleeping on all occasions when the nurse checked on them, for the patient that interruption to their sleep, coupled with the strange bed and strange sounds of the hospital ward, may well feel like a very poor night’s sleep indeed.

For some patients, clearly the question of sleep becomes almost a side issue as they require constant attention throughout the night. However, in the routine ward situation it is hoped that the patient will sleep for much of the night, but it is still good nursing practice to observe patients at regular intervals. Here the most accurate and definite report that the nurse can give is to report on the patient’s sleep status as at the time of observation — for example: ‘Patient observed at regular intervals (if possible mention the time). When so observed the patient was sleeping’. Obviously where the patient does not sleep it should be appropriately and accurately reported.In conclusion on this point, the use of ‘appears’ in the context outlined should not be used.

Entries in reports should be made at the time a relevant incident occurs. This is known as ‘contemporaneous reporting’. Nurses have traditionally written their reports at the completion of each shift. There is no legal reason for this and it would be more appropriate to make a relevant entry as soon as possible after an incident or episode of care occurs. Not only will the nurse have better recall of the event, in some cases if the nurse waits until the completion of the shift to record an occurrence, that episode may have been overtaken by subsequent events — particularly if a patient’s condition worsens and various treatments are commenced and tests undertaken. Trying to recreate the accurate sequential order at that stage can prove confusing. Any entry that is made should be prefaced by the date and time and followed by the nurse’s signature.

Abbreviations should not be used in reports unless they are accepted healthcare organisation abbreviations. The diversity of healthcare organisations in which nurses and other health personnel train and later work leads to a similar diversity of abbreviations used — often with confusing and misleading results. Every healthcare facility, as a matter of administrative policy, should have a list of accepted abbreviations accompanied by the accepted interpretation of each abbreviation. No other abbreviations should be used in the patient’s records. It is also critical that those abbreviations are accepted by all healthcare professionals, as different professional groups can use the same acronyms or abbreviations to describe different phenomena related to their own area of practice.

If medical terminology is used in reports, the nurse must be sure of the exact meaning, otherwise it could prove misleading.

Any errors made while writing an entry in a patient’s record should be dealt with by drawing a line through the incorrect entry and initialling it before continuing. Total obliteration of the incorrect entry may suggest that there is something to hide. Writing over mistakes with emphasis and inserting words left out between lines can also cause confusion and misunderstanding, and should definitely be avoided. Liquid correcting fluid should never be used to correct mistakes.

A number of factors are worth remembering that may reduce the risk of an incorrect entry being made.

– Don’t make an entry in a patient’s record before checking the name on the record.

– Don’t make an entry in a patient’s record by an identifying room or bed number only. Patients are known to have been moved while staff are absent (e.g. during a meal break) and remembering a patient simply as ‘the patient in bed 12’ can sometimes cause incorrect entries to be made in the chart at the end of bed 12 (apart from any other considerations).

– Make sure that the patient’s name and identifying number is on every sheet of the patient’s record before making an entry on that sheet. Some observation sheets are single sheets which are not immediately incorporated into the body of the patient’s record. If these single sheets are not identified before any entry is made, there is the risk that the wrong patient’s observations may be recorded on the sheet unwittingly or the sheet may be wrongly identified after an entry is made and then filed in the wrong patient’s record.

– Avoid wherever possible making notes concerning a patient on loose paper for rewriting into the patient’s notes. Not only is it common for such scraps of paper to be lost, but every time an entry is transcribed in this fashion there exists a margin for error in the transcription itself and there is the risk that the entry will be made in the wrong patient’s notes. It is also duplication of work and therefore time-wasting.

No entry concerning the patient’s treatment should be made in a patient’s record on behalf of another nurse. Examples of this have unfortunately arisen, particularly in relation to fluid balance charts. For example, in one case a registered nurse on night duty had experienced a particularly busy night, the majority of her time being taken up with a very sick child. Apart from any other problems, the child wet the bed frequently during the night. No entries recording this fact were made by the registered nurse on night duty after 01.00 and before the completion of her shift at 08.00. The registered nurse who came on duty at 07.45 noted this fact and, remembering that she had been told that the child had wet the bed several times, she then proceeded to fill in the child’s fluid balance chart by writing ‘PU+ +’ a number of times on the chart at such times that she presumed the child may have wet the bed. The child subsequently died and because of the events leading up to the child’s death, a coronial inquest was held. During the inquest, the child’s fluid balance chart came under close and critical scrutiny. When questioned in the Coroner’s Court as to why she had made the entries on the child’s fluid balance chart when she clearly wasn’t on duty, the nurse replied that she had only intended to do the nurse on night duty a ‘favour’, as she obviously hadn’t had time to make the entries during the night. The Coroner was critical of such practices.¹

Integrated record keeping

Integrated report writing in the patient’s record is essential. In the past, nurses and medical officers traditionally wrote separate reports about a patient and these reports were separately filed. It would not be incorrect to suggest that on many occasions neither party read the reports of the other. That such a situation ever arose is odd enough — that it might continue would be clearly unsatisfactory and contrary to good practice.

In order to obtain a comprehensive picture of the patient’s condition and progress, it is essential that the reports of all health personnel concerned in caring for the patient be part of an ongoing integrated holistic record. It is also much safer, as it requires all personnel involved in caring for the patient to read the reports of other colleagues. Not only is such an undertaking instructive and illuminating for everybody, but it must also help to ensure that all personnel are aware of what is happening to the patient — clearly the most important consideration of all. Most hospitals have already introduced such an integrated system and it is to be hoped that the rest will soon follow suit.

Reading the patient records

There is a need to ensure that nurses read their patients’ records thoroughly and regularly. Many hospitals and some healthcare centres rely on a system of verbal reporting at the commencement of each shift as the major way of passing on the history and any relevant information concerning the patient that has arisen during the previous shift. If the nurse is unfamiliar with the patient, the written record should be read for the nurse to have a more extensive overview of the patient.

Clearly the verbal handover is generally an efficient way of quickly reporting on all patients to all relevant staff on a shift-by-shift basis. The verbal report must be, of course, an addition to the written report. The problem that can arise is that, having received the verbal report, nurses do not bother to read the patient’s record as well. As a result, important information and/or pathology results that may not have been mentioned in the verbal report are not known and noted, sometimes until it is too late. The following example illustrates this point.²

A young man recovering from an emergency appendicectomy did not make the expected uneventful recovery. He was unable to keep fluids or food down, he had diarrhoea, a spiking temperature pattern and complained of extreme abdominal pain. A chest X-ray and a microurine were negative. On the morning of the fifth post-operative day, a Saturday, the registrar ordered a full blood count to be done that day. The results were returned to the ward that afternoon after the registrar had gone home off-duty, although remaining on call for the weekend.

The results showed a considerably raised white cell count and other abnormal results indicative of some form of severe infection. The significance of these results would presumably be readily grasped by the ordinary reasonable registered nurse. The registered nurse on duty filed the pathology result in the appropriate place in the patient’s record and made no further comment about it. That was on Saturday afternoon. Obviously other registered nurses came and went during the course of the weekend but none of them read the patient’s record completely. Not only were the nurses’ reports written separately from the medical officer’s, but the nurses relied on the verbal handover received at the commencement of each shift.

The pathology result was not raised until the following Monday afternoon. The patient subsequently died from peritonitis and the question of the delay in the notification of the pathology result clearly became an issue raised by the relatives’ legal representative during the coroner’s inquest which followed. It was not the conclusive issue, but the example serves to illustrate the importance of taking the time to read the patient’s record thoroughly.

This case ultimately ended up in court. The young man’s mother sued the hospital and the hospital staff for negligence in the care of her son and sought compensation for loss of income dependence under the New South Wales Compensation to Relatives Act 1897 as well as nervous shock. The case, reported as McCabe v Auburn District Hospital, was heard in the Supreme Court of New South Wales.³ On the basis of the facts as outlined above and the evidence presented, the judge upheld Mrs McCabe’s claim against the hospital and staff. The hospital acknowledged their vicarious liability for the actions of the medical and nursing staff of the hospital at the outset of the case.

In arriving at his conclusion of negligence on the part of the hospital and its staff the judge saw fit to make critical comment on the accuracy and reliability of the medical and nursing notes, particularly having regard to evidence given by other patients and Mr McCabe’s friends and relatives as to his deteriorating condition. The following extracts on this issue appear in His Honour’s judgment:

I am of the view that the hospital notes are not, in the current case, reliable. In particular there is unreliability in recording the manifest and observable continuing deterioration of the deceased’s condition. I am satisfied that the routine temperature checks even if accurate as to scale were accompanied by failure to note what was there to be seen, namely that the deceased was perspirant and ‘hot’. This was evident even to non-medical appreciation … I do conclude … that there were things significant in assessing the patient’s deterioration which were overlooked and the written record simply does not truly reflect the currency of events.⁴

And further:

It follows that the inability of the (medical staff) to perceive the deterioration in the patient’s condition was inhibited by the inadequacy of the clinical and nursing notes.⁵

And again:

It would be apparent from my earlier findings and remarks that I conclude that the clinical and nursing notes were deficient. Their inadequacy must have been a major factor in bringing about a situation which allowed the patient’s condition to deteriorate fatally without timely remedial treatment.⁶

The value of good nursing records when used as evidence in court

Sometimes the quality of the nursing record has been high and this has been advantageous for nurses in terms of both their verbal evidence ⁷ and their written evidence.⁸ In the case of Spasovic v Sydney Adventist Hospital⁹ the patient claimed that the nurses employed at the hospital and the doctors who cared for him failed to exercise reasonable care in assessing and treating complaints made and symptoms he exhibited, in particular a headache, which were caused by a small cerebral haemorrhage from an arterio-venous malformation (AVM) in his brain. He claimed that, because of their failure to assess and treat him, he was discharged from hospital without the small cerebral haemorrhage or the AVM having been diagnosed, and later on the same day he suffered a major cerebral haemorrhage from the AVM, which caused him to have very serious permanent disabilities.

The healthcare records were a central plank of the evidence offered in defence by the hospital and the medical staff. The lawyers representing the hospital made the following representation as reported by the judge, James J:

It was submitted by counsel … that I should accept the Hospital’s medical records and particularly the Hospital notes (that is the Integrated Progress Notes), as reliable evidence and indeed the most reliable evidence concerning the plaintiff’s headache and events happening during the plaintiff’s stay in the Hospital.

As was submitted by counsel for the first defendant, the Hospital’s medical records and particularly the Hospital notes have the virtues, as evidence, of being contemporaneous records; of having been made by or under the supervision of trained observers; of having been made, not for the purposes of litigation or out of self-interest or with hindsight, but for the purpose of disinterestedly recording, progressively, what was happening during the plaintiff’s stay in the Hospital; and of being, on the face of them, quite detailed and not merely perfunctory.

The virtue of having been made without hindsight, that is of having been made without knowledge of the plaintiff’s major haemorrhage on 20 January 1996 and its consequences, is a virtue possessed by the entries in the Hospital notes and by very little other evidence, lay or expert, in the case. I have also had the benefit of seeing and hearing many of the nurses who made notes give evidence and I formed a generally favourable impression of them.¹⁰

The judge concluded that he had decided, in general, to accept the records as being ‘an accurate record of the matters purportedly recorded in them’.¹¹ This case provides a striking example of how good records, made with the sole purpose of providing good nursing care, not only furnished evidence as to the existence of good nursing care but also enabled the judge to find both the written and verbal evidence provided by the nurses to be reliable.

The difficulties for nurses when their records produced in court are poor

Unfortunately, on numerous occasions the poor quality of the nursing records has meant that the courts have (understandably) taken them literally and found their depiction of nursing care wanting. Perhaps because nursing has such a strong oral tradition, the nursing records have never been the major focus of authenticity for nurses.¹² Greater reliance has traditionally been vested in the oral nursing handover.¹³ Thus, questions such as ‘at what time did you take Mr Smith’s 6 o’ clock observations?’, however illogical they may sound to listeners, are a consequence of the fact that 4-hourly observation charts are often pre-printed with the times, 2, 6, 10, 2, 6, 10.¹⁴ This type of chart should no longer be used as it results in a number of anomalies. For example, if a nurse has a caseload of eight patients, only one can have their observations recorded exactly on the hour. In addition, the records often take the form of graphs or plans, meaning times are abbreviated or rounded off to save space. However, if an observation is taken and found to be abnormal, and particularly if a patient is seriously ill or a patient’s condition is deteriorating, the exact time of the observation must be written.

This does not excuse poor recording practices, but it goes some way to explaining them. Clearly this is problematic for nurses who would wish their records to be accorded professional authority. Especially when witnesses have poor recollection of events, judges rely on written evidence, meaning that nurses who do not produce accurate records will find it difficult to have their account of a particular incident treated as legitimate if it is inconsistent with the written evidence. When nurses’ charts and times have been tendered in courts and tribunals, and have been found to be inaccurate, the nurse witness’s credibility has suffered as a consequence. For example, a finding that ‘these times were all approximate times, were not accurate times and cannot be relied upon’ led to the judge declaring that ‘I accept [the anaesthetist’s conflicting] evidence in view of the inexactitude of the nurses’ times as shown by the contradictions on the charts’.¹⁵ The occurrence of inaccuracy in the nurses’ records elicits considerable irritation in the judgments.¹⁶ Although medical practitioners’ records have also been the objects of judicial criticism, there is a stronger written culture in medicine and thus perhaps a tendency to greater accuracy.¹⁷ This has often enabled their records, and thus their evidence, to carry more weight than those of nurses. This reinforces the significance patient records can have in legal proceedings. It also underscores the importance nursing staff should place on recording their entries in an accurate, objective and timely manner, taking into account the whole of the patient’s condition.