Report Writing

1. Specialist Training Report Writing

2. Next Back Home Welcome… Welcome to this web based knowledge session on Report Writing. It should take you approximately 10 minutes to complete this material. How to use this pack To go to the next page, please click the button. To go to the previous page, please click the button. To go to the first page, please click the button. To display additional points on a page click the button. Additional information will be displayed in a separate font. Blue bullets indicate how many times you have to click to display all the information. Show Me

3. Aims & Objectives… By the end of this session you will have knowledge of: Why we need to keep records. What you should record. How you should record this information. Problems with record taking. Examples of records. How to take good records.

4. Why do we need to keep records? Record keeping is an essential part of providing care. The CSCI Minimum Standards for Domiciliary Care outline: “The health, rights and best interests of service users are safeguarded by maintaining a record of key events and activities undertaken in the home in relation to the provision of personal care, …” Equally the Nursing and Midwifery Council (NMC) says: “Record keeping is an integral part of nursing, midwifery and specialist community public health nursing practice. It is a tool of professional practice and one that should help the care process. It is not separate from this process and it is not an optional extra to be fitted in if circumstances allow.”

5. Why do we need to keep records? Care is not just provided by one person, so records are essential in helping different teams interact and communicate in order to deliver the best care possible for the service user. They should enable you to provide the right care for your service user regardless of where they are in the care process or care environment. Good records are essential in enabling a smooth transition between the different care teams, they are the product of good teamwork and an important tool in promoting high quality care.

6. Why do we need to keep records? Another extremely important reason for keeping records is that they can be called into evidence in order to investigate a complaint at local level or for criminal proceedings. The approach to record-keeping that courts of law adopt tends to be that ‘if it’s not recorded, it didn’t happen’. It is therefore important that all relevant points are noted as analysing evidence that has gaps in it is very difficult. The records serve as an audit trail and are there to equally protect the Service User as well as protect yourself.

7. Why do we need to keep records? You have a professional and a legal duty of care and therefore your record keeping should demonstrate: Show Me A full account of your assessment and the care that has been planned and provided. Relevant information about the condition of the Service User. The measures taken to respond to the Service User’s needs. Evidence that you have understood and honoured your duty of care, that all reasonable steps have been taken to care for the Service User and that any actions or omissions on your part have not compromised their safety in any way. A record of any arrangements that have been made for the continuing care of the Service User.

8. What should I record? The Domiciliary Care Minimum Standards list the following points that need to be recorded: Show Me Assistance with medication incl. time and dosage on a special medication chart. Other requests for assistance with medication and action taken. Financial transactions undertaken on behalf of the service user. Details of any changes in the users’ or carers’ circumstances, health, physical condition and care needs. Any accident, however minor, to the service user and/or care or support worker. Any other untoward incidents. Any other information which would assist the next health or social care worker to ensure consistency in the provision of care.

9. How should I record information? The Minimum Standards say that all records must be legible, factual, signed and dated and kept in a safe place in the home, as agreed with the service user, their relatives or representatives. They should be written in black ink and any amendments must be made by crossing through the existing words, keeping them legible and initialling the change. Under no circumstances should records be rubbed out or crossed out in such a way that they become illegible. If you do have to make an alteration, you must date, time and sign the record.

10. How should I record information? The NMC lists these points as factors that contribute to effective record keeping. Service User records should: Be factual, consistent and accurate. Be written as soon as possible after an event, providing current information on the care and condition of the service user. Be written clearly and so that the text cannot be erased or deleted without a record of change. Be written so that any justifiable alterations or additions are dated, timed and signed or clearly attributed to a named person in an identifiable role in such a way that the original entry can still be read clearly. Be accurately dated, timed and signed, with the signature printed alongside the first entry. Not include abbreviations, jargon, meaningless phrases, irrelevant speculation and offensive subjective statements. Be readable on any photocopies.

11. Problems with record taking… A number of common problems with record keeping have been identified (Dimond 2005, HSC, 2003 – 2004) Failure to transfer patient details on continuation sheets Failures in communication between healthcare professionals Entry of information on an identity band or clinical documentation Spelling mistakes e.g. error in name resulting in wrong diagnosis Too much jargon Failure to record action when problem identified Inaccurate records e.g. recording treatment that did not happen Failure to record telephone calls, e.g. on risk of suicide • Failure to document • Conversations • Care given • Special needs Missing information

12. Problems with record taking… To show the importance of record taking and the consequences of poor record taking, consider this example. A London Trust found itself facing an investigation by the health service commissioner after nurses had failed to record the next of kin details of an elderly woman who later died on the ward. All attempts to trace the woman’s family failed. As a result, her grandson learnt of his grandmother’s death three weeks later when a cheque she had sent him was returned by the bank marked ‘drawer deceased’. Not surprisingly, he lodged an official complaint, which was upheld by the commissioner.

13. Examples of records… Hopefully you will never come across an example as serious as this, but you can see how small omissions can have a profound impact. So consider some of these examples and see whether you would record information in a similar way or whether you think it could be improved. Mr Jones asks for pain killers frequently Show Me the verdict The problem with this statement is the word ‘frequently’ as this is very open to interpretation. You may think frequently means every 2 hours, another person may think it means every half hour. To improve the record it needs to be more specific about the time frame.

14. Examples of records… Mrs Miller got up by herself and fell. She should not have been out of bed. Show Me the verdict This statement is an opinion rather than an objective description of what happened. Found Mrs Miller on the floor. No apparent injuries. Show Me the verdict This is more objective, however ‘No apparent injuries’ is very vague and may make the reader question how thoroughly you checked the service user for injuries. If this was to be used during an investigation it may indicate negligence.

15. Examples of records… Mrs Miller found on the floor next to her bed by care worker Julie Jones. Floor dry and clean, service user walking against advice and complaining that she was feeling dizzy. Mrs Miller questioned and checked over by Julie Jones, no apparent injuries. Physician notified for detailed check up. Show Me the verdict This statement is objective, detailed and complete. This is the best example to report the incident.

16. Taking good records… At the beginning of this module we have already discussed what needs to be recorded and how this needs to be done. Please make sure that you go over these sections again if necessary. Below are some examples of the types of words that you should avoid along with better substitutes, although the list is not exhaustive.

17. Review… This session has covered information on taking care records and the importance of their completeness and accuracy. Care notes are an audit trail and will protect the service user as well as the carer. They are not additional to delivering care but are an essential part of it and allow smooth transitions between care teams. The module covered what needs to be reported as well as how this should be done. You have seen examples of good and bad reports with advice on how to improve the ones that were not correct.

18. Well done! You have now completed this web based session on Report Writing. Please now complete the assessment on Report Writing.