Sylvie Hampton: Documentation

There are different issues that I find with documentation. One of the things nurses will always say to me is, I would rather look after my patient than do the documentation. And that is right across the country and it drives me mad because it is part of looking after your patient, to have the written record. And the expert witness cases that I do, there are two issues there. One is the documentation is extremely poor in the cases that I do and the other is that the nurses are reactive to a problem and not proactive. So they will actually say that this patient has a red sacrum, a red sacrum day after day and then suddenly there's a black sacrum and they say we must put them on an air mattress. So they're actually being reactive to a problem instead of being proactive. the Department of Health says that you know if somebody's going to look after a patient if you do everything you possibly can to protect that patient against that problem and they still get it then it's not your problem but if you haven't done everything despite the condition of that patient if they get a pressure ulcer then it's your responsibility and I actually work by that when I'm looking at expert witness cases I want to know did you do everything and I don't expect essays to be written. Sometimes I get essays and I don't really want to know. There's masses of things sometimes written down but they're all irrelevant. None of them seem to give me that information that I need about what they did for the patient. So documentation is extraordinarily important but nurses very often don't give it that importance and don't actually fulfill what they need to fulfill with data. A, it shows us how the patient is doing. B, it protects us against court and nurses think they're safe against court and they're not. There are all sorts of ways they can find themselves in court, coroner's court, civil law, they can even find themselves in criminal law. If a person dies of a pressure ulcer or a leg ulcer and didn't need to die, that is a criminal case. And then there's the NMC. Nurses can always find themselves in the NMC if they've not done their documentation appropriately. And if they haven't done it, they haven't given the care. And so it actually needs to be firmly there. But as I said, it doesn't need to be essays. Tick boxes, to my mind, are more than adequate if you're signing the box next to it to say that you are the one that's responsible for giving that care. Photographs are also important and one of the things that we're finding is that some trusts won't allow photographs and that's fine, you can't take a photograph if the trust doesn't allow it, but if you are allowed to take photographs they should supply you with the equipment to do it and you shouldn't keep it on that equipment. The minute it's downloaded to the patient's notes it has to be wiped. One of the things we should know is that it's never truly wiped, it can be gained back and data protection means that we have to guard against people taking that information. We also have to make sure that when we're doing photography that we don't put any identification on it. I had a photograph sent to me by a patient the other day and he's lying on a bed with his foot out and the relatives had taken a picture of his foot but there he is at the top end of the bed looking straight down into the camera with all his relatives sort of alongside of him. So you You know it's not something that you could actually use and certainly it's something we shouldn't be doing as professionals. You know if we do need to take a picture it needs to be of the wound and it only needs to have the patient's name or identification on it if it's for their notes. If we use it for other reasons like research which we can do with the patient's full permission and full knowledge of how it will be used, we need to make sure there's no identification on it and we also have to make the patient aware that no matter what they do with it, it can be picked up by other people and used by them on the internet. You know I had a photograph that I took or my medical photographer took and I used it in a journal article with the patient's permission and then the other week I went on to the internet and I found that same photograph had been used by a consultant in America as an example of what it would look like if somebody has frostbite on the top of a mountain, and I'd not give them permission, let alone the patient. So that's sort of a legal thing, really. One of the things that I have found is that nurses will put pressure area care given. It means not a thing to me. I mean, it could mean that they're hanging from the ceiling and all their pressure's relieved because they're hanging from the ceiling. It doesn't mean a thing to me about what they actually did. If they reposition, shall we say, two-hourly, I don't believe in the two-hourly terms, but let's say two-hourly, and they say, I've repositioned this person every two hours this afternoon and signed their name next to it, I will believe it because they've signed their name there and they will be expected to be in a court of law answering to that. I much prefer to see things like repositioning charts at the bottom of the bed that they can tick and sign and I'm perfectly happy with that as well. So repositioning charts and those sort of things are perfect to my mind. We shouldn't be spending huge amounts of time writing things that are unnecessary and what I see are these great essays that say you know the patient had their bowels open and they walked to the toilet and they had a good wash and all of that means nothing to their care if they've got a pressure ulcer or a leg ulcer, you need to know if they've got a leg ulcer, what the size of the wound is, what shape the wound is, what colour it is. And I so rarely see that in the notes that I deal with. If I go round to the leg clubs, I can look at their note taking and I can see all those things are documented in leg club notes. But the cases I get are all bad cases and all I'm seeing is that the nurses are not providing the documentation and I think that's the reason that they're in court is because they're not providing the right documentation. Sometimes you see the wound charts and they're not fully completed and if they've missed one or two that's okay because in law omitting one or two things is not a problem. But if it's consistently missed, and you're not getting the information, that's where the problem lies. So if you have a wound care chart, it needs to be completed, but if it's not completed 100%, I'm not going to fight that, as long as I can see the picture of the wound and how it improves or deteriorates. There are several things with documentation. One is that you need that data to say how you're actually doing as a trust. You need to know you need to be able to audit and find that you're doing a really good job from the documentation. You also need to say that you personally are doing a good job and that you're writing exactly what's needed, what's required in a court of law and you always have to remember that there is a chance you will end up, even if it's in a coroner's court, answering for what you've written. So it's really important to know that. But the documentation should be clear and it should be written well and I think doctors go to university to learn how to write badly and I also think if they write badly they're not going to be had in a court of law because nobody can understand what they've said and they can say anything they like. I'm absolutely convinced their writing is the worst I've ever seen in my life but some nurses go that way as well and you see them writing really neatly but you understand what they've said and if they haven't written it down it's not being given and so they need to be concise with what they're saying and make sure that their care is actually documented properly. In note-taking quite often people use abbreviations and text speak and that is not good. Sometimes I have to actually go onto the internet and find out what something means and interpret it for the lawyers because they won't, if I don't know, the lawyers are not going to know what it actually means and perhaps on doing that I'm getting the interpretation wrong. So we need really to make it very clear in the notes what we're actually saying and text speak is not the right way forward for note taking.