Monday, September 8, 2008

Poor Record Keeping has Midwife Cautioned

An experienced midwife was cautioned by the NMC for failing to maintain accurate records and then falsified records once she realised she had made an error. The midwife failed to maintain appropriate records which lead to a patient being given the contraceptive drug Depo-Provera while the woman was pregnant. When the midwife realised her mistake and that the patient was pregnant, she falsified the previous entry by adding the words "last menstrual period - first day 11.5.2005" and two weeks later made a further entry - "remembered conversation with patient".

This raises the question of lying to save yourself, however, the fundamental behavior of our nurses and midwives is that of “trustworthiness” that honesty is the best policy – to be dishonest brings our profession into disrepute. Our Codes of Conduct clearly give us guidelines of how to behave and what the expected standards are, this is clearly a breach of these standards.

The ANC did take into account the midwives good record, and that her actions did not result in direct or indirect harm to the patient and the subsequent outcome for the patient was not as a result of her actions. However the committee did find that the inaccuracy of recording and the incidents of falsifying records were not of the standard required of a registered nurse/midwife and resulted in misconduct.

"Nurses are required to adhere to their Code of conduct which says that they should act in a way to uphold the reputation of the profession. The panel considered her behaviour to be unprofessional and dishonest and outside of the NMC's guidelines on record keeping which say that "records should be written in such a manner that any alterations or submissions are dated, timed and signed in such a way that the original entry can still be read clearly".

The midwife had produced good testimonials and that this behaviour was out of character, also the midwife had been dedicated to the profession of nursing and contributed to academic teaching and nurse training.
The report also stated that “last year nearly 10% of the cases that went to a full hearing were to do with poor record keeping”.

Nurses and Midwives need to remember that accurate record keeping is a fundamental part of their practice. Poor sloppy documentation (record keeping) equals a non professional attitude.

Remember if it is not written it is not done!



Suzanne said...

I do agree with "not written = not done". I always have problems with the newly graduated nurses or sometimes fellow batch mates and senior nurses. They seldom document the relevant and significant events. When I need to look back the report for certain events, I just cannot get any information out of their reports. Even highly trained staff in ICU are also guilty of poor documentation.

I still can remember one incident where my Junior (also a RN) and me have to scrutinise all the doctors notes and nursing reports just to find out when was the chest tube removed. We gave up eventually and called the ICU. None of the nurses who nursed him could provide us with the information. In the end, we have to speak to the nurse clinician directly. It is such embarrassment that as you go on nurses, your skills and knowledge improves yet such things still happens. The fault also lies with the receiving nurse, who is very senior, overlooked that information.

What is a good documentation? Writing accurate and significant events with the date and time and signed off by the RN IC. I've met incidents when patients complains and I was never usually called up as my reports were sufficient enough to cover myself and my junior, sometimes even my manager if she is involved. The only time I was called up was when I was working as Junior and my IC did not write a proper report. I had to write a memo and also to see my nurse manager just to explain what I did that day. Nothing serious happened, its just that documentation can save up a lot of time and trouble.

From what I understand about the education system here and my country, the preaching for documentation is the same. Sometimes its during the time of forgetfulness, or slackness, or the overwhelming of events that lead to poor documentation. Whichever the case, for patient's life, there is never 'cut some slack' for us all in the health care. When did we actually cut a slack for ourselves? When we are fully taking a break and not working?

Nonetheless writing a report is never difficult, practice makes perfect. Save the patient. Save yourself and save those looking after the patients too.

infomidwife said...

Thanks Suzanne, you make some valid points. I think as health professionals we need to constantly remind our colleagues about good documentation. It is a sign of our professionalism and needs to be promoted and encouraged by management as a priority. When caring for our patients/clients anything abnormal needs to be reported, documented, plan of action, then followed up and again document the resuts.
It is when things go wrong (patients complaining about their care or litagation) our notes are scrutinised and if it is not written it is not done!

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