LITERATURE REVIEW: ON THE IMPORTANCE, PROBLEMS AND SOLUTION OF HEALTH RECORD KEEPING IN HOSPITAL

CHAPTER TWO

 LITERATURE REVIEW

2.1 Introduction

Record-keeping is an integral part of health care service in hospital, Midwifery and Allied Health Professionals’ practice and is essential to the provision of safe and effective care. It is not an optional extra to be fitted in if circumstances allow (NMC 2009).

Records include anything that makes reference to the care of the patient and any record can be called as evidence as part of:

1. Coroners’ inquests or criminal proceedings

2. Nursing & Midwifery Council’s Fitness to Practice Committee.

3. Trust Investigation Panels

4. NHS Professionals’ disciplinary investigations

The approach to record keeping that courts of law adopt tends to be that ‘if it is not recorded, it has not been done’. Good record keeping helps to improve accountability and shows how decisions related to patient care were made (NMC 2009).

        A person's medical records are amongst the most sensitive of personal records and great care should be taken to ensure the safe holding of such records. Apart from their sensitive nature, there is also the very practical consideration that they can be of considerable clinical value in relation to the ongoing care of a patient. Their primary purpose is to document the assessments underlying the progress of the patient's care and so contribute to the quality of that care. As months or years may elapse between treatments or illnesses, and staff may have moved on, the records should serve to reconstruct events at a later date without recourse to memory. Poor record keeping can lead a patient's care being adversely affected through;

an increased risk of medication or other treatment being duplicated or omitted, communication problems between staff, both nursing and medical, a failure to focus attention on early sigs of change in a patient's condition, and a failure to place on record significant observations and conclusions.

They can also be of great importance in cases alleging medical negligence, or other such litigation, and they may be of value to the family of a patient after he or she has died, provided, of course, that their release is justified in any particular case.

It is the experience of this Office, however, that when we have had occasion to examine patient files we have often found them to be unsatisfactory as a record of the various elements of a period of hospitalization. International research shows that Ireland is not unique in this situation. Reports in the UK reveal a lack of structure, disorganization, illegibility, absences of problems or diagnoses. Similar problems were revealed in Australia. In Spain 15% of records reviewed were so illegible as to be rendered meaningless. It is beyond comprehension that caring professions can be so lax in this regard. Such practice could only be described as being akin to a (no doubt unintentional) level of disrespect and disregard for the patient.

The retention and efficient management of patients' records should be a key responsibility. In this context the Ombudsman would expect that such records would be legible, intelligible, complete, specific, contemporaneous, signed and dated. Abbreviations should be universally understandable and not open to misinterpretation. They should be written with care (a slip of the pen can easily change the meaning of an abbreviation); that makes life easier for all hospital personnel using the records, for the hospital administration in dealing with any complaint and, ultimately, for the Ombudsman if she has reason to include such records in the examination of a complaint. In addition certain abbreviations are unacceptable (e.g. coded expressions of exasperation, invective or sarcasm).

      Effective record keeping benefits all medical practices. It improves the efficient day-to-day operation of your practice; helps record and maintain your patient information and enables transparent reporting.

There are other benefits related to effective record keeping. These include maintaining the security of confidential clinical files, supporting staff to do their work more effectively, improving staff retention, and enhanced
business continuity.

Having adequate administrative records may also assist if you are ever asked to participate in an Australian Taxation audit, Medicare compliance auditor for accreditation purposes. It is important to understand that record keeping obligations differ depending on the purpose of the records. You may also not be aware that neglecting record maintenance may increase the risk of receiving an incorrect Medicare payment or mean that you are not able to provide adequate evidence to substantiate claims.

The Administrative Record Keeping Guidelines have been designed to provide you with a range of helpful suggestions, general information and guidance to assist you to implement and maintain adequate record keeping systems that you may find beneficial for your practice.

 FACTS ABOUT HEALTH RECOD KEEPING

Below are 10 simple tips that may be beneficial in establishing and maintaining an effective administrative record keeping system. The benefits of maintaining accurate, reliable and useable records can help to increase the efficiency and effectiveness of the practice business. It will ensure your practice is able to access information when required and meet all accountability and compliance business requirements.

1. Planning

    Establish what processes are needed for administrative records to be effectively maintained and how this will be achieved. Planning an administrative record keeping process will help you maintain a record keeping system that works for your practice and provides clear expectations for practice staff.

2. Consistency

    To make it easier for practice staff to do their job, have information collected and stored in a consistent way within your practice; all staff should follow the same policies and procedures.

3. Communication

    Have all your staff made aware of, and ensure they understand, administrative record keeping policies and procedures. By communicating expectations clearly, you will benefit from consistent administrative record keeping standards within the practice.

4. Training

    Know the capabilities of your software and provide appropriate training to staff. Most software used in practices today has capabilities that will make it easier for you to keep accurate administrative records. Training your staff in record keeping will benefit your practice by increasing the reliability and consistency of your practice and patient records. This will also reduce staff frustration when records cannot be located quickly and easily.

5. Allocate appropriate resources

    Allocate the appropriate resources needed to maintain your records, for example, staff and physical resources. By doing this, you will be able to better manage your administrative records effectively, leaving staff feeling supported and more positive about their position. You may choose to make the Administrative Record Keeping Guidelines a part of the range of record keeping guidance tools that you have available for staff in your practice.

6. Modify

    Don’t be afraid to modify your record keeping system if you find a more efficient way to achieve results. Regular reviews of your record keeping systems will keep them up-to-date and operating in a way that is beneficial to the practice.

7. Embrace technology

    Regularly investigate if new technology is available that may help improve the efficiency of your administrative record keeping system. Practice staff will appreciate any efforts made to improve the task of keeping records, giving them additional job satisfaction.

8. Delegation

    Nominate your practice champion—delegate responsibility for monitoring administrative record keeping practices to a staff member who will enjoy the challenge, accept responsibility and remain accountable. Having a nominated champion will enable staff to remain focused on your record keeping policies and procedures and identify where improvements could be made.

9. Responsibility

    Know your responsibilities—what to record, how to maintain records and how long they should be kept. You should also consider your obligations if asked to participate in a Medicare compliance audit. Having accurate and reliable records during an audit will allow you to easily confirm that the Medicare payments you received for services were correct.

10.    Review

    Encourage staff to provide feedback on how the record keeping system is working and how it could be improved. In doing this, you may gain valuable suggestions that will bring continuous improvement to your administrative records, improving the efficiencies of the practice.

OTHER DOCUMENTS TO KEEP IN THE HOSPITAL RECORD

• Your health log or diary: - Description of symptoms or health problems you are having
  - Dates and reasons for doctor's office or emergency room visits and hospitalizations
  - Written instructions and advice from your doctor
  - What to expect from treatment and when to return to your doctor if you don't improve
  - Side effects or unusual problems with medications you are taking
• Copies of important medical records, including lab tests, radiographic reports, operative reports and consultation reports
• Your insurance plan Explanations of Benefits
• Receipts for your payments for health care
• Correspondence and personal notes of phone calls related to your health care
• A copy of your Advance Directives or Durable Power of Attorney
• If you move, have a chronic illness and/or frequent hospitalizations, or are dissatisfied with your care, you may want to request copies of your medical records from your doctor and hospital.

DEFICIENCIES IN HEALTH RECORDS KEEPING IN HOSPITAL

            Deficiencies in those standards were given concrete reality in a particular case dealt with by the Ombudsman, in which the care and treatment afforded to a patient in the days prior to his unexpected death were under consideration. In that investigation the Ombudsman found a paucity of records covering critical treatment junctures, a stark failure to meet the standards of medical record keeping expected of medical staff following their contact with the patient and an absence of relevant entries on the nursing notes during a period of significant nursing intervention. The paucity of the records made it difficult to establish precisely what happened during the period in question. The absence of medical note entries following examinations raised the question as to how any doctor, who was subsequently called to examine the patient, could quickly apprise himself or herself of the patient's condition, in particular where a previous, but unrecorded, medical examination was significant in terms of diagnosis or treatment. The Ombudsman recommended that the hospital review its procedures to ensure (i) that entries on the nursing records created by nursing staff accurately reflect the contacts made with medical staff for the purposes of patient review and the reason that the contact was made; (ii) that all significant observations on a patient's condition that are made to members of the medical team by the nursing staff are recorded on the nursing notes. Furthermore, the Ombudsman recommended that the responsible health board take action to ensure that all the hospitals under its control meet the standards outlined in the recommendation. The Board accepted these recommendations in full by way of : 

(i) The development of a programme of nurse education relating to best practice in the maintenance of nursing notes, followed by a chart review and audit of nursing documentation to determine the effect of the programme, and generally to monitor documentation.

(ii) The development of a new module in the induction programme for non consultant (Junior) doctors, concentrating on best practice for medical notes.

PROBLEMS OF HEALTH RCORD KEEPING IN HOSPIAL

A number of common problems with record-keeping have been identified (Dimond2005, HSC, 2003-2004). These are:

· Absence of clarity e.g. the meaning of 'Had a good day' and ‘slept well’ is not

clear

· Failure to record action taken when a problem is identified, e.g. 'is suffering

increasing pain' then no record of action taken

· Missing information, e.g. administration of a drug not documented

· Spelling mistakes, e.g. error in name resulting in wrong diagnosis

· Inaccurate records, e.g. changing a dressing or giving medication, when infact the patient had not received the recorded treatment (leading to a nurse being removed from the Register)

· Failure to document conversations

· Failure to document care given

· Failure to document special needs

· Failure to record telephone calls, e.g. on risk of suicide

· Failures in communication between healthcare professionals

· Too much jargon

· Patient identification, e.g. entry of information on an identity band, clinical documentation and failure to transfer patient details on continuation sheets.

SOLUIONS TO HEALTH RECORD KEEPING IN HOSPITAL

1. Health care professionals have a duty to keep up to date with, and adhere to,

relevant legislation, case law and national and local policies relating to

information and record keeping (NMC 2009).

2. Handwriting must be legible and written in blank ink to enable legible photocopying or scanning of documents if required.

3. Records must be accurate and written in such a way that the meaning is clear (NMC 2009) (HPC 2008).

4. Records must demonstrate a full account of the assessment made and the care planned and provided and actions taken including information shared with other health professionals.

5 All entries in a record must be dated (to include date/ month/ year), timed accurately and signed.

6. All entries in a record must be recorded as soon as possible after an event has occurred, providing current information on the care and condition of the patient/ client

7. All entries in a record must be recorded, wherever possible, with the

involvement of the patient/ client or their career and written in language that the patient can understand.

8. Records must demonstrate any risks identified and/ or problems that have arisen and the action taken to rectify them (NMC 2009)

9. First entries on each page of the record must include the printed name and signature of the person recording the information.

10. Abbreviations, jargon, meaningless phrases or offensive statements must not be included in any records.

11. In the event of an error being made, entries must be corrected by striking the error through with one line, and applying the author’s initial, time and date, by the correction. The original entry should still be read clearly. Errors must not be amended using white correction fluid, scribbling out or writing over the original.

12. Records must never be falsified CG2 – Record Keeping Guidelines Clinical Governance V3 March 2010

13. Health care professionals must develop communication and information sharing skills as accurate records are relied on at key communication points, especially during handover, referral and in shared care.

14. Legal requirements and local policies regarding confidentiality of patient records must be followed at all times

15. Health care professionals remain professionally accountable for ensuring that any duties delegated to non-registered practitioners are undertaken to a reasonable standard and records made by pre-registration nurses/midwives or care support workers are countersigned (NMC 2005) (HPC 2008)

HOW TO IMPROVE HEALTH RECORD-KEEPING IN HOSPITAL

By adopting the following habits, nurses should avoid problems related to record-keeping:

·         - Get into the habit of using factual, consistent, accurate, objective and unambiguous patient information;

·         - Use your senses to record what you did, such as ‘I heard’, ‘felt’, ‘saw’, and so on;

·         - Use quotation marks where necessary, such as when you are recording what has been said to you;

·         Ensure there is a reasoned rationale (evidence) for any decision recorded, for example, denying access to a visit from children;

·         - Ensure notes are accurately dated, timed, and signed, with the name printed alongside the entry (initials should be avoided);

·         - Follow the SMART model (Specific, Measurable, Achievable, Realistic and Time-based) or similar when planning care;

·         - Write up notes as soon as possible after an event and, by law, within 24 hours, making clear any subsequent alterations or additions;

- Document any objections you may have to the care that has been given;