Chapter 18: Record-keeping and documentation

Case study: Mrs Mary Davies

Mrs Mary Davies is a sixty year old woman with mild learning disabilities who has been admitted to a general ward after a road traffic accident. She suffered an injury after hitting her head on the steering wheel while coming home after a night out on the town. The car she was driving crashed into a tree and she was later found to be over the drink drive limit. Mary is from a close knit community and is very assertive in expressing her needs. She did not really want to be admitted to hospital but her family insisted that she stay in for at least one night. The other patients did not take to her as they felt she was too overbearing. She woke early in the morning with a headache and painful shoulder and neck. She made her way to the nurses’ station to complain to the nurses about the noise from the other patients keeping her awake. There was a difference of opinion over who was making the noise as the other patients complained about Mary’s behaviour. Mrs Davies insisted on being moved to another ward or side room. There was a shortage of beds that day and patients were waiting to be admitted from the Accident and Emergency department and other hospitals. At breakfast Mary did not like the breakfast and threw it on the floor still complaining about her pain. The duty doctor was called and Mary was prescribed a muscle relaxant and stronger analgesia on regular prescription for the next 24 hours instead of her as required milder analgesia. She went off to sleep later that afternoon. Staff nurse, Peter Williams, was on duty from 8–4.30 pm.

Compare and contrast entries A and B regarding the above case study and decide which one most meets the NMC (2015) code guidance on record keeping. Make a note of both good and bad points

Entry A

Date

Comments

Signature

2/10

The patient got up in a foul mood and was very abusive to staff. There was no good reason for this or why she threw her dinner over the floor other than she has a learning disability. The other patients dislike her and have asked me to move her off the ward as she scares them. In the afternoon she was given her prn meds as she was still very moody and not at all remorseful for her actions.

ƒƒ

 

Entry B

Date

Comments

Signature

2/10/13

0500 hours

 

 

 

 

0900 hours

 

 

1230 hours

 

 

 

 

 

1600 hours

Mrs Davies awoke at 0430 hours and got out of her bed and walked to the nurses’ station. She alleged that she had been woken up by two of the patients snoring and that ‘they were doing her (she used F word) head in’. She also stated that she wanted to be moved to a (she used F word) side room so that she can get some sleep. It was explained to her that there were no free side rooms at present and she would have to wait until one became available but that would be dependent on other patient’s needs.

 

At approximately 0830 hours Mrs Davies threw her breakfast plate, full of food onto the floor shouting that her (she used F word) head was killing her. The duty doctor was called at 0900 hours

 

Duty doctor arrived at 1200 hours midday and prescribed Ibuprofen 400 mg and Diazepam 2 mg every 8 hours a day after examining her (see medical notes for full account). He felt that Mrs Davies had a neck spasm due to the accident and also poor sleeping posture although she insists it was due to the noise made by two other patients. These two patients blamed Mrs Davies for the noise and disruption on the ward. At 1430 hours she was given her medication of Ibuprofen 400 mg and Diazepam 2 mg (see drug chart for full prescription details).

 

At approximately 1500 hours Mrs Davies rested on her bed, appeared pain free and eventually went off to sleep.

Susan Harries

Night sister

 

 

 

 

Peter Williams

Staff nurse

 

Peter Williams

Staff nurse

 

 

 

 

Peter Williams

Staff nurse

 

› Solution

You should have noticed that entry A was not very good in terms of accuracy, errors and providing personal opinion. There were no times provided and just two letters in terms of staff identification. The most concerning aspect was the negativity towards Mrs Davies by the nurse making the entry? It was very one sided, personalised and seemed to imply that Mrs Davies was not very popular and was very troublesome possibly due to her learning disability. If you contrast this entry with entry B then a more balanced approach has been adopted. Dates, times and the individual nurse making the entry are clearly identifiable. The events are put into order and a number of entries are made during the span of the nurse’s shift. The nurse Peter Williams has provided factual information and has resisted the temptation to take sides and give an opinion. He has also included swear used but has stopped short of the actual spelling out of the full term. Some clinical areas insist on this and others do not and are content for just an F word was spoken. There is an assumption that everyone knows what F word was spoken. However, even with this entry you are left wondering what other care has been provided other than the incidents and visit from the doctor. For example, did Mary have another breakfast or drink? Was she seen by a physiotherapist or pharmacist?

Considering the reason Mary was admitted to hospital was due a car accident, would you know if this was Mary’s usual behaviour or could it be a sign of a head injury? Both record entries do not tell us what observations had been undertaken or her current neurological status. There is also no indication of any other care she actually received besides what has currently been recorded. Both records fail to identify any pain assessment despite the fact Mary complains that her head is ‘killing her’. Can you tell from these records Marys problems and responses to interventions? Finally, as Mary has a known learning disability, there is no recorded evidence that her capacity to make decisions has been assessed.

Remember that if it is not recorded it is deemed not to have taken place.