We have all heard something along the lines of ”If it’s not written down, did it happen?”
While this question could keep philosophers pondering into their old age, nurse employers, the Health Practitioners Disciplinary Tribunal or the Coroner will form a view rather more quickly. As a lawyer, I have asked clinicians this type of question and it is not pleasant watching them try to answer – I have no doubt that it was even less pleasant for them than it was for me.
This article outlines nurses’ professional responsibility to make accurate clinical notes in a timely manner. It also provides guidance on how to write high quality clinical notes that play an important part in patient care and could provide nurses with a degree of protection should the care they delivered (or even the care delivered by a colleague) be called into question.
The primary purpose of clinical record-keeping is to facilitate the planning and delivery of safe and effective nursing care – it is easy to lose sight of this, especially when you are so busy actually delivering that care.
Try to avoid thinking of clinical notes being to ‘cover your back’ in case anything goes wrong; good clinical notes, focused on appropriate patient observations and care are likely to protect nurses if the care and treatment of a patient is called into question. Poor clinical notes undermine the quality of that care, increase workload and make nurses vulnerable to legal and professional problems.
A nurse’s professional obligation regarding clinical notes
All nurses must practice in accordance with the Nursing Council of New Zealand’s Code of Conduct for Nurses. The Code sets out the standards of behaviour that nurses are expected to uphold in their professional practice. Principle 4 of the Code provides that a nurse must “maintain health consumer trust by providing safe and competent care.” Principle 4 contains twelve distinct standards, the eighth (4.8) of which is: Keep clear and accurate records.
The Code provides some guidance in respect of such records:
- Keep clear and accurate records of the discussions you have, the assessments you make, the care and medicines you give, and how effective these have been.
- Complete records as soon as possible after an event has occurred.
- Do not tamper with original records in any way.
- Ensure any entries you make in health consumers’ records are clearly and legibly signed, dated and timed.
- Ensure any entries you make in health consumers’ electronic records are clearly attributable to you.
- Ensure all records are kept securely.
What should your clinical notes contain?
The first point to make is that, no matter how busy nurses are, they should write a note in the first place. The old adage ‘If it’s not documented, it didn’t happen’ really is a good one to keep in mind. If, for whatever reason, you didn’t write your clinical note, your claim that “I’m sure I did this, it’s what I always do” will not be given much credence by the powers-that-be.
The next point to make is that when nurses make a note, make sure it is a good one. A good clinical note is not one in which the nurse rewrites War and Peace but one in which the relevant clinical information is conveyed in a concise manner. It takes the same amount of time to write a good 30-word note as it does to write a bad 30-word note.
While it may seem obvious, put the date, time and a title for your entry (e.g. ‘Initial Assessment’, Progress Note’ or ‘Treatment Plan’) – electronic records often prepopulate these fields, but if they don’t or you’re handwriting a clinical note, make sure this information is included. All too often, an otherwise-decent clinical note is weakened by not having the time recorded and when something was or wasn’t done can be extremely important in deciding whether that act or omission was reasonable or not in the circumstances.
Very importantly, make sure that your notes are legible. If they can’t be read, it leaves the content open to interpretation and this can prejudice your patient’s care.
When writing your notes, avoid jargon; it is a real skill to be able to convey a message using simple, clear language which maximises the likelihood that someone reading it will understand it. Remember that other members of the clinical team will be reading and considering what is written, to guide their own clinical decision-making.
Nurses need to use their professional judgment as to what is relevant information and how they are going to describe it. One way of ensuring that a clinical note captures the relevant information is to use the ‘SOAP’ approach:
- Subjective information – this is what the patient or others give you.
- Objective information – what you can see, feel, hear and measure (e.g. observations and investigations).
- Assessment – what do you conclude from the information you have to hand?
- Plan – what are you going to do about it? If you’ve done something, note what effect it had. Do you need to do anything further?
Nurses also need to be considered in their thinking. Nurses don’t have the time to always check where every piece of information came from, but the more significant that piece of information, the more effort a nurse should put into checking it. If you’re going to write ‘NKDA’ (for no known drug allergies) write down how you know this, for example “patient advised me that she has no known drug allergies”.
When finished writing the note, make sure that you sign it and identify your designation (e.g. RN Smith).
How can I get even better at writing clinical notes?
A really good way to improve clinical writing skills, apart from considering the matters described already, is to read colleagues’ notes. We all know someone who writes fantastic notes – clear, concise yet telling you what you need to know. Think about adopting their style – over time you will find that you will develop your own style, but this is a great starting point.
Also look online for guidance on writing clinical notes – there’s no shortage of good suggestions. If you are not sure about what you have written, ask a colleague to read it and tell you what they understand it to mean.
Clinical notes are a central part of everyday nursing practice. Nurses have to write them and when they want to know something about a patient they read what has been written by others. You know what you think and feel when you struggle to read scruffy notes that leave you none the wiser about the patient – don’t give others an opportunity to find fault with your clinical notes, particularly people who have the power to decide whether you can continue to work for them, or work as a nurse at all. :
Disclaimer: The content of this article is general in nature and not intended as a substitute for specific professional advice on any matter and should not be relied upon for that purpose.
The writer welcomes feedback on this article and can be contacted at firstname.lastname@example.org