What is a nursing record?
The nursing record is where we document the nursing care the patient receives and their response to it, as well as any other events or factors that may affect the patient's well-being. These 'events or factors' can range from a visit by the patient's relatives to going to theatre for a scheduled operation.
What should go into a patient's nursing record?
If you are in doubt about what to write, it may be useful to ask yourself the following: āIf I was unable to give a verbal handover to the next nursing team, or the next shift, what would they need to know in order to continue to care for my patients?ā You want to ensure that the patient's care is not affected by the changeover of nursing staff.
How to keep good nursing records
The patient's record must provide an accurate, current, objective, comprehensive, and concise account of their stay in hospital. Traditionally, nursing records are hand-written. Do not assume that electronic record keeping is necessary.
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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.
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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.
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Ensure a supply of continuation sheets is available.
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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.
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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.
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On admission, record the patient's visual acuity, blood pressure, pulse, temperature, and respiration, as well as the results of any tests.
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Clearly state the diagnosis, as well as any other problems the patient is currently experiencing.
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Record all medication given to the patient and sign the prescription sheet.
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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.
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Ensure that the consent form for surgery, signed clearly by the patient, is included in the patient's records.
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Include a nursing checklist to ensure the patient is prepared for any scheduled surgery.
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Note all plans made for the patient's discharge, such as whether the patient or carer is competent in instilling the prescribed eye drops and whether they understand the details of follow-up appointments.
Writing tips
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Ensure that statements are factual and recorded in the order in which they occur. Only record what you, as the nurse, see, hear, or do.
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Do not use jargon, meaningless phrases, or personal opinions (e.g., āthe patient's vision appears blurredā or āthe patient's vision seems to be improvingā). If you want to comment on changes in the patient's vision, check the visual acuity and document it.
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Do not use an abbreviation unless you are sure that it is commonly understood and in general use. For example, BP (blood pressure) and VA (visual acuity) are commonly used and are safe to use in records.
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Do not speculate, make offensive statements, or use humour when referring to the patient. Patients have the right to access their records!
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If you make an error, draw one clear line through it and sign next to the correction. Do not use sticky labels or correction fluid.
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Write legibly and in clear, concise sentences.
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Remember, some information provided by the patient may be confidential. Consider carefully whether it is necessary to record such information in writing, where it may be accessible to others; all members of the eye care team, as well as the patient and their relatives, have the right to access nursing records.
Looking after nursing records
Store the nursing records in a location where they can be easily accessed, preferably near the nursing teamās meeting area during shift changes. This ensures that records are available during handover sessions and are easily accessible to the rest of the eye care team. The handover may take place with the patient present, if appropriate. Nursing records can only be accurate if patients are involved in the decision-making process related to their care.
File the nursing records in the medical notes folder on discharge. Ensure that the whole team knows if nursing records are stored elsewhere.
References
Stevens, S., & Pickering, D. (2010). Keeping good nursing records: a guide. Community eye health, 23(74), 44ā45.
