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Extending Independent Nurse Prescribing within NHSScotland
ANNEX B
POLICY STATEMENT - RECORD KEEPING
All records created and maintained by health professionals should provide accurate, current, comprehensive and concise information concerning the condition, treatment and care of the patient/client and associated observations.
Properly made and maintained records will:
Be entered within 48 hours of events to which they relate.
If the date of the entry does not coincide with the date of the contact with the patient then the date of the entry, actual time of visit and the date of the contact must be recorded.
Be written legibly and indelibly. Each entry must be signed with full signature and dated.
Be clear and unambiguous.
Be accurate in each entry as to date and time.
Alterations must be made by scoring out with a single line.
OTHER FORMS OF ERASURE OR DELETION - SUCH AS THE USE OF CORRECTION FLUID - MUST NEVER BE USED. The correct entry should then be initialled, dated and timed.
Additions to existing entries must be individually dated, timed and signed.
Be written in terms which patients/clients will be able to understand.
All professionally-held records must be stored in a secure manner in a locked file, drawer or cupboard.
Systems for storing and record keeping will exclude unauthorised access and breaches of confidentiality.
Meaningless phrases and offensive subjective statements, unrelated to patient care must not be used.
Abbreviations are only acceptable from a locally agreed list.
POLICY STATEMENT - RECORD KEEPING AND NURSE PRESCRIBING
All nurses are required to keep contemporaneous records, which are unambiguous and legible.
In addition:
A. The record of the nurse's prescription must be entered into the patient's records as close as possible to the time of writing the prescription.
B. Where more than one record exists (e.g. a Trust nursing record and the hospital or GP record) information must be entered into each record as soon as possible.
C. The record should clearly indicate the date, the name of the prescriber, the name of the item prescribed, the strength (if any), and the quantity prescribed. In hospitals the date and time of the last dose to be given may be used in place of a quantity to be dispensed. For preparations to be given or taken at a fixed dose or interval, the duration(s) of treatment can be recorded in place of prescribed quantity.
For medicinal preparations, (items to be ingested or inserted into the body), the dosage schedule and route of administration must be stated, e.g. Paracetamol oral suspension 5 ml 4 hourly.
For topical medicine preparations, the quantity to be applied and frequency of application must be included.
D. In some circumstances, in the clinical judgement of the nurse prescriber, it may be necessary to advise the patient's doctor immediately of the prescription.
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