Over the last few years in SA, the dramatic rise in neonatal litigation has highlighted the need for improved clinical record keeping. While it is critical that there is accountability within the health system when errors do occur, in many cases the health care provider or institution is unable to defend the care given due to the poor quality of the clinical records. The generally accepted rule is that “If it isn’t recorded-it wasn’t done”

Some common errors in record keeping include:

  1. Illegible  handwriting
  2. Lack of dates, times and signatures
  3. Incomplete, scanty or missing documentation
  4. Subjective rather than just factual entries
  5. Use of abbreviations
  6. Lack of documentation regarding medication or treatment that wasn’t given
  7. Not questioning illegible entries or orders
  8. Entering data on the wrong chart
  9. Adding entries out of chronological order

As I travel and visit many different neonatal units I am frequently struck by the volume of nursing entries and the often scanty medical entries. The challenge I find is with what is recorded by the nurses.

An entry might read: Mother reports baby is doing well. Observations: T= 36.7⁰C, Pulse= 134 bpm, Resp= 56 bpm, Saturations= 92%. Assessment: Baby is stable. Continue with management

As you can see this doesn’t provide much insight or information that can’t be found elsewhere in the clinical record and really adds no value. A more comprehensive systems based assessment is required but this can often be long winded and time consuming.

Observations are generally comprehensively completed at the required times but it is apparent that nurses are not thinking about what they are recording. The Nursing Process appears to be an abstract concept they learnt about years ago in college not a living process to guide their care.

Assessment. Nursing Diagnosis. Planning. Implementing. Evaluating. Each step needs to be completed before we can progress further in the process.

When a nurse observes/assesses her patient the goal should be to detect a problem, make a plan about what to about it, implement the plan-take action and then reevaluate to assess whether the action was effective. Unfortunately in many cases the nurses appear to stop after the first step. They document observations. There is no identification of abnormal observations or the problem found, no action is taken and the observations are only repeated again at the routine time. It appears as if the goal is to have a beautifully completed record not to document the condition of the patient and interventions given.

This negatively impacts on care and outcomes. Commonly hypothermia is not detected or acted upon. Research has proved for every 1C drop in temperature below 36⁰C- sepsis risk increases by 11% & mortality risk increases by 28%   (T. Cordaro et al 2012.)

Likewise saturation and oxygen levels are well documented but no action is taken particularly for high saturation levels in the presence of oxygen. This immediately increases the risk of Retinopathy of Prematurity and the possibility of resultant litigation.

These are the basics of nursing care and do not require an advanced diploma or degree in order to implement.

In KZN, after a lengthy process of review and consultation, a new set of standardized neonatal records have been produced. These records have attempted to reimagine how a clinical record looks and functions.

In developing the records the following objectives were considered- the records must:

  1. Be neonatal specific
  2. Be comprehensive and accurate
  3. Be accessible and attributable
  4. Be appropriate for level of care (Hospital/Bed)
  5. Reduce the time taken in recording
  6. Improve the quality of what is recorded
  7. Support improved quality of clinical care rendered
  8. Facilitate multidisciplinary recording.

The new records include the following changes:

As with any new record –it is only as good as the person completing it. A record can only support provision of quality care, not guarantee that it is delivered! It is therefore crucial that, when aiming to improve record keeping, there is effective and frequent supervision and mentoring from leaders and monthly structured auditing of the records. In KZN this auditing process includes both the quality of the record and the quality of the care recorded (a clinical audit). A minimum of 5 records are audited every month. This audit process must include both nurses and doctors.

With the chronic nursing shortage in most units there was initially skepticism and resistance to the introduction of these records with units stating they are too long & of too high a standard, but following thorough orientation and increased familiarity hospitals report satisfaction with the tools. The process of rolling out these records is still underway. Buy in is better at level 1 hospitals where there are smaller teams. Some doctors at level 2 hospitals object to the structured format and prompts and yet their records are historically poor. Correct use of the records is still poor with some users just leaving out parts of the tool with which they are unfamiliar. Ongoing support and guidance will be required to assist facilities with implementation. Implementation of the monthly record/clinical audits and ongoing mentoring will raise awareness of what is required and support monitoring of compliance. Only time will tell, but hopefully this will sustainably improve quality of clinical care and recording.

So I challenge you to assess the records in use in your units and to ask:

  • Do they meet the objectives stated above?
  • Is your unit conducting frequent, structured, multidisciplinary record audits?
  • Are you proud of your records-do they reflect the standard of care you want for your patients?
  • Is it time for a change?

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