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Record keeping and the community nurse

02 February 2024
Volume 29 · Issue 2


Iwan Dowie discusses the need for appropriate record keeping in community nursing. Through a series of legal examples, a case is made for good documentation, with suggestions that include factual, eligible and well-written records.

Record keeping is an integral part of community nursing practice and there is an obligation placed upon the community nurse to record good, clear and accurate information about their patients (Royal College of Nursing, 2023). NHS England (2023) also affirms that nursing and midwifery practice is ‘supported by good documentation that supports professional decision making and care’. However, record keeping can be challenging, especially in busy clinical environments and if you are a community nurse with a large caseload, record keeping can often be seen as a burdensome extra. Nevertheless, from a legal perspective, a general defence of being busy is not an acceptable one (McCormack v Redpath Brown [1961]). This article aims to illustrate the importance of record keeping from both a legal and professional perspective.

This obligation to provide good documentation generally derives from our contract of employment (Griffith and Dowie, 2019). However, there is also a need to be able to evidence the care and treatment undertaken by the community nurse. Records can take various forms; these include written notes, electronic and paper, email, care plans, video recordings and photographs or anything where a patient/client's care has been recorded by the community nurse. Failure to provide evidence of care via record keeping will place the community nurse at risk of being unable to su ciently defend their practice, either at a disciplinary hearing or a court of law. As reiterated by Stevens and Pickering (2010), if a complaint is made against you, your record of care is often the only proof to show that you had met your duty of care to the patient. In the case of Saunders v Leeds Western Health Authority [1993], a normally t 4-year-old girl experienced a cardiac arrest while in the operating theatre and consequently, suffered brain damage, blindness and quadriplegia. The theatre sta claimed that her pulse had stopped abruptly; yet, there was no evidence in the records of this claim. Normally for negligence to be found proven, a direct causational link needs to be established (Herring, 2018). However, in this case, the court took the view that it is not normal for a t 4-year-old girl to experience a cardiac arrest if appropriate protocols are followed, and that there was a lack of evidence from the records in providing a narrative to why the cardiac arrest occurred. The court was of the opinion that the practitioners were liable for the harm caused.

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