Question

what would you do if you have no/very little case information?

Answer 1

In general keeping good nursing records allows a nurse to identify problems that have arisen and the action taken to rectify them.

In the busy working day of a nurse, with the many urgent demands on your time, you may feel that keeping nursing records is a distraction from the real work of nursing: looking after your patients.

This cannot be more wrong! Keeping good records is part of the nursing care we give to our patients. It is nearly impossible to remember everything you did and everything that happened on a shift. Without clear and accurate nursing records for each patient, our handover to the next team of nurses will be incomplete. Needless to say, this can affect the wellbeing of patients.

In fact, the quality of our record keeping can be a good (or bad) reflection of the standard of care we give to our patients: careful, neat, and accurate patient records are the hallmarks of a caring and responsible nurse, but poorly written records can lead to doubts about the quality of a nurse's work.

Another important consideration is the legal significance of nursing records. If a patient brings a complaint, your nursing records are the only proof that you have fulfilled your duty of care to the patient. According to the law in many countries, if care or treatment due to a patient is not recorded, it can be assumed that it has not happened. Poor record keeping can therefore mean you are found negligent, even if you are sure you provided the correct care - and this may cause you to lose your right to practise.

In short, the patient's nursing record provides a correct account of the treatment and care given and allows for good communication between you and your colleagues in the eye care team. Keeping good nursing records also allows us to identify problems that have arisen and the action taken to rectify them.

How to keep good nursing records

The patient's record must provide an accurate, current, objective, comprehensive, but concise, account of his/her stay in hospital. Traditionally, nursing records are hand-written. Do not assume that electronic record keeping is necessary.

• Use a standardised form. This will help to ensure consistency and improve the quality of the written record. There should be a systematic approach to providing nursing care (the nursing process) and this should be documented consistently. The nursing record should include assessment, planning, implementation, and evaluation of care.

• Ensure the record begins with an identification sheet. This contains the patient's personal data: name, age, address, next of kin, carer, and so on. All continuation sheets must show the full name of the patient.

• Ensure a supply of continuation sheets is available.

• Date and sign each entry, giving your full name. Give the time, using the 24-hour clock system. For example, write 14:00 instead of 2 pm.

• Write in dark ink (preferably black ink), never in pencil, and keep records out of direct sunlight. This will help to ensure they do not fade and cannot be erased.

• On admission, record the patient's visual acuity, blood pressure, pulse, temperature, and respiration, as well as the results of any tests.

• State the diagnosis clearly, as well as any other problem the patient is currently experiencing.

• Record all medication given to the patient and sign the prescription sheet.

• Record all relevant observations in the patient's nursing record, as well as on any charts, e.g., blood pressure charts or intraocular pressure phasing charts. File the charts in the medical notes when the patient is discharged.

• Ensure that the consent form for surgery, signed clearly by the patient, is included in the patient's records.

• Include a nursing checklist to ensure the patient is prepared for any scheduled surgery.

• Note all plans made for the patient's discharge, e.g., whether the patient or carer is competent at instilling the prescribed eye drops and whether they understand details of follow-up appointments.