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1.The nurse did not adhere fully to the principles of good record keeping. Firstly there was no record of any admission observations, so there was no baseline to compare with. In her statement there is no indication of date or time and she only signed as S/N Smith instead of using her full name because there maybe another S/N Smith in the institution. There was absence of clarity within her statement, vague descriptions of the findings of the patient. She stated that they were "fine"..... what does that mean?  Her statement also seemed as though she was directing blame away from herself.
However she did take action and documented it when she realized the patient's blood pressure was elevated.

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Ms. Smith did not follow the steps of record keeping and delegating a  task.
Steps in delegating a task:
- only delegate tasks and duties that are within the other person’s scope of competence, making sure that they fully understand the instructions.
- make sure that everyone they delegate tasks to are adequately supervised and supported so they can provide safe and compassionate care.
- confirm that the outcome of any task delegated to someone else meets the required standard .
Ms Smith is held liable due to her not following the steps from above which may cause harm to the client. No records  of her vital signs was documented before and post medication. In some case vital sign assessment must be done first before and medication administration.

Keep clear and accurate records relevant to your practice

This applies to the records that are relevant to your scope of practice. It includes but is not limited to patient records.

To achieve this, you must:

10.1 complete all records at the time or as soon as possible after an event, recording if the notes are written some time after the event

10.2 identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need

10.3 complete all records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements

10.4 attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation

10.5 take all steps to make sure that all records are kept securely

10.6 collect, treat and store all data and research findings appropriately

(Jevon 2012; RCN 2017)

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Proper record keeping was a failed incident in this scenario. Nurse Smith maybe through no fault of hers was seemingly drowning on her shift and to add insult she had a student to tutor. Although the student was a second year pupil and was supposedly already exposed to drug administration and basic vitals documentation , Nurse Smith was accountable and responsible for all that had transpired on her shift. The Student nurse was under her watchful eyes and should have been supervised regardless of how busy the shift was. All events for the day should have been registered especially from the time that the medication error occurred. Supervision should have increased and not left up to the student who may have already been under so much pressure with the medication error. In the event that this patient had died Nurse Smith had nothing documented to aid her plea and argument that it wasn't her fault. If it wasn't documented, it wasn't done. These words always ring true in nursing and professions as a whole.

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Nurse smith who is a registered nurse  has the responsibility to supervise and mentor the student nurse who was assigned to work with her  who is inexperienced and also not licensed to exercise autonomy of her own as regards to patient's care. effective management of the patient would have included good communication skill , nurse Smith would have instructed the student nurse, as the  duty of accountability on this incident , falls on nurse smith. Her documentation was also inadequate.
Failure and  inadequate record keeping can cause harm to the patient, Detailed report of every actions and omissions as regards to patient's care should always be documented, for instance, time of incident, actions, individuals involved,  effects or harm to patient should have been properly documented and signed , adequate documentation would be very necessary in case of any legal action by the patient involved.     it is important to note that having a busy shift should not be a reason for failing to document or inadequate documentation.

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Nurse Smith did not adhere to the principles of record keeping firstly she did not take responsibility for her actions , there were no baseline assessment so there was nothing to compare ,her report was based primarily on subjective data rather than objective . She failed to be accountable or share the responsibility with the student nurse , there were no documentation of the how the problem was dealt and what measures was taken to ensure the patient's safety the sequence of the event was documented in chronological order .

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As a student nurse I was always told that I'm practicing on the staff nurse licence that I'm assigned too. With that in mind, it's Nurse Smith duty to ensure that student was supervised. V/S were not done on admission or following administration of medication. Dr's orders was not carried out as requested ex. V/S Q1/2 H. Incident form should have been filled at beginning of shift stating staff  shortage and ward is extremely busy. Incident report giving detailed account of event and measure taken need to be recorded and reported. In my opinion never assume where a nursing student educational level at but to assess same. Nurse Smith placed her patients at risk and should be held accountable.

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Staff nurse Smith did not adhere to the principles of reordd keeping

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Principles of good record keeping: Staff Nurse Smith Scenario

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Principles of good record keeping: Staff Nurse Smith Scenario

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Staff nurse smith failed to apply many of the principles of good record keeping. She did produce a statement recollecting the events of what occurred which mentioned that she did let the doctor know that the medication error had occurred. However, she failed to state the date and time which the error had occurred neither the date and time that the incident report had been written. The NMC code states 10.1 complete all records at the time or as soon as possible after an event, recording if the notes are written some time after the event.10.4 attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation.
Proper record keeping was also not taken on admission and also when the task was delegated to the same student nurse who made the medication error. Also Nurse Smith fails to be accountable for the medication error, no admission observation, or vital signs when the patient was asked to be monitored. She was the one who delegated the task therefore she was responsible for ensuring that it was done and done correctly. NMC code also states that
Be accountable for your decisions to delegate tasks and duties to other people

To achieve this, you must:

11.1 only delegate tasks and duties that are within the other person’s scope of competence, making sure that they fully understand your instructions

11.2 make sure that everyone you delegate tasks to is adequately supervised and supported so they can provide safe and compassionate care

11.3 confirm that the outcome of any task you have delegated to someone else meets the required standard .

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Principles of good recording- Nurse Smith

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Principles of good recording- Nurse Smith

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NMC (2015). The Code: Professional standards for practice and behaviour of nurses and midwives. London: NMC (10 of the code) sets out the principles for good recording keeping:

10 Keep clear and accurate records relevant to your practice

This applies to the records that are relevant to your scope of practice. It includes but is not limited to patient records.

To achieve this, you must:

10.1 complete all records at the time or as soon as possible after an event, recording if the notes are written some time after the event

10.2 identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need

10.3 complete all records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements

10.4 attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation

10.5 take all steps to make sure that all records are kept securely

10.6 collect, treat and store all data and research findings appropriately

Nurse Smith applied some of the principles with direct reference to 10.1 to 10.4 of the code.

She returned as soon as possible after the incident with the other patient to complete and document the procedure in the patient’s chart, which is how she identified the medication error. She did not hesitate to take appropriate action and inform the doctor.

However she didn’t mention in her statement if she documented the incident in full in the patient’s chart which is essential for other health team for safe continuity of care and to avoid litegation.

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Record Keeping Scenario

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Staff nurse Smith failed to apply the principles of record keeping. The actual time of the event is unclear. No baseline assessment was done or recorded. Her records are based on subjective rather than objective information. She does not focus on the problem, how it was addressed or handled and what the immediate outcome or solution was. She fails to be accountable or share responsibility with the student nurse. There are no information about how this error affected the patient and or what steps were made to ensure the patient's safety.

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The principles of record keeping was not displayed in the scenario. The staff nurse provided all the reasons as to why the events occurred but she never took accountability or responsibility for the events that occurred as a result of her actions.  Firstly, no baseline data was obtained on admission which is very vital, hence when the patient's BP stated to increase, there was no baseline data to compare it to. Furthermore, once the medication error occurred, she's still displaying the blame game. The SN is responsible for the student, the student is functioning on her license, therefore, the five rights of drug administration should have been discussed and documented. The student should not have been left unattended to administer medication. Secondly, if the student nurse could not fulfill the task of drug administration, why was the she left to monitor the same patient. It was the SN responsibility at this point to monitor and chronologically document the events and the actions taken i.e how the incident occurred, time, date, vital signs, level of consciousness, actions taken and the time.
In my work place, I totally understand the importance of proper documentation. We are also faced with the dilemma of staff shortage, but a very high patient ratio which of course leaves you at risk for litigations. The phrase, " document with the Judge in mind" has always stuck with me and what is not documented was not done.

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In this scenario Nurse Smith did not adhere to the principle of good record keeping. There was no date and time the incident occurred as well as signature. She delegated the task to the student nurse without supervising her. She guessed that the student nurse should know how to administer medication thereby delegating the duty to her without supervision. There was no initial admission observation done on the patient as it was not documented. Nurse Smith did not asses the competency of the student nurse before assigning her to give the medication. Nurse Smith is blaming the student nurse as she does not want to be responsible for her actions. There is no handing over of the patient care. There was no record on what was done on the patient when the student nurse was on break. The standard of documentation was poor.

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Staff nurse Smith did not adhere to the principle of good record keeping according to the NMC code(2015). No date ,time or baseline vitals were shown in her record.
She also passed blame on the student nurse knowing fully well that the student nurse should be under supervision by her.she delegated a duty to a student without assessing her understanding of the instructions. She also did not follow up on the patient or document what actions were taken following the incident.

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Principles of Good Record Keeping

Some key factors underpin good record keeping. The patient’s records should:

Be factual, consistent and accurate;

Be updated as soon as possible after any recordable event;

Provide current information on the care and condition of the patient;

Be documented clearly in such a way that the text cannot be erased;

Be consecutive and accurately dated, timed and all entries signed (including any alterations);

All original entries should be legible. Draw a clear line through any changes and sign and date;

Not include abbreviations, slang or jargon as not all workplaces or organisations will use the same terminology;

Records must be stored securely and should only be destroyed following your local policy;

Avoid meaningless phrases, speculation and offensive subjective statements/insulting or derogatory language;

Identify the patient by recording patient’s name, date of birth and hospital number on each page of the record (three approved identifiers) or follow your local policies on how to identify patient’s records;

Still be legible if photocopied or scanned.

(Jevon 2012; RCN 2017)

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the nurse didnt apply the principles of record keeping. She spoke about being short staffed but that won't change the fact she delegated work to the student twice without supervision even though the student gave the wrong medication. The vitals information wasnt even recorded, one of the most important information needed to give accurate care. The Nurse will be help accountable and responsible for not performing her duty effectively.

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Accurate record keeping is an essential part of maintaining accountability and patient safety.
In the scenario, the nurse failed to adhere to many of the principles of good record keeping.
From here statement, it can be seen that not much record keeping was done to begin. Actions were taken that were not recorded, much less dated. No risks were highlighted and actions taken to alleviate them.
With that, the nurse has removed all responsibility from self. Furthermore, her competency can questioned for not properly assessing the student under her care and delegating tasks that required her supervision. After the incident, the nurse did not see it fit to acquire base line data for the client to compare for progress report. Blame was cast on the student.

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In the scenario concerning Nurse Smith it is noted that she did not adhere to the principles of record keeping. After the incident there was not recording of initial assessment of the patient or vital signs recording as to allow one to compare the baseline from what exist before to  when patient started experiencing pain and palpitation, there was no recording of date and time of the incident, nor was there any continuity of care after the event happened,
According to 'The Code' (1) one must complete all records at the time or as soon as possible after the event (2) Identify any risk or problem that may have arise and (3) making sure that the student she delegated task to was adequately supervised and supported, so that the care provided will be safe and compassionate care.
In my opinion the nurse did not properly assess the skills of the student before delegating  tasks and duties that are within the scope of her competency, and the student and as a result did not meet the required standard needed to be held responsible. As a result of all this the nurse should be more cognizant and vigilant in proper record writing that may not implicate her in the court of law.

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In the scenario concerting the SN Smith, the nurse did not adhere to principles of good record keeping, the initial assessment for the patient was missing so to follow up on the patient symptoms was not possible. Vital information is not available the statement is very vague, the date and time of the of the event and the time of the statement cannot be determined. Her statement in some areas is based on her personal through and opinion. Her assessment of the patient condition is not clearly written to outline to the reader what specifically is happening to the patient. No time of calling the doctor to the time he responded was noted. Her signature was not appropriate there can be more than one nurse Smith working at the institution. Legally and professionally the nurse implicated herself more based on the action she took in caring for this patient.

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Ms. Smith was faced with the challenge of being short staff on that day. She delegated the task to the 2nd year student but failed to supervise the student. Due to her action the patient was placed at a disadvantage and developed complications post medication error. Ms. Smith however, did the right thing by reporting the matter to the doctor. Ms. Smith failed to record proper documentation because the record of the admission blood pressure was not recorded so therefore they were unable to make a caparison with the present blood pressure.  The action of the nurse could put the institution at risk for litigation or lawsuits.  The topic of record keeping makes you as the nurse become more aware of the importance of documenting properly.

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Ms. Smith was faced with challenges on her job because the unit was short staff on that day. Although she delegated to the 2nd  year student while she carried out other orders or procedures, she failed to supervise the junior staff. This then caused the patient to be wrongfully medicated and was not monitored properly post the medication error. Due to poor documentation the doctor was uable  to compare previous records with the present.

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Nurse Smith delegated the task of administering the medication to the patient by the student nurse. Upon administration of the medication, Nurse Smith realise an error was made and the Doctor was informed. When examining the patient it was also realised that no base line vital signs was documented on patient admission/arrival.
Effective record keeping would have included documenting the patient vital signs, allergies to any medication. the patient name age and address must also be documented. Any event such as the one that had occur should be documented, any actions taken as well as informing the patient and his next of kin if the incident. Once again the student was given the task of monitoring the patient. It seem like Nurse smith was too busy to care for and document the relevant information relating to the patient. If this becomes a case of negligence, Nurse Smith cannot use being to busy as her defence. However with proper and timely documentation to show the events leading up to the incident, it can show the true nature of what occurred and why it did.

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It is evident that Nurse Smith was not adhering to the principles of proper record keeping . Proper record keeping should begin from the time of admission to include subject and objective data assessments and observations. It is obvious that important   admission recording was not done because there was no baseline blood pressure available from admission.
10.1 of the NMC code states that all records should be completed at the time or as soon as possible after the event.  Even after the error was made with the administration of the medication  the RN still did not assess the competence of the student to ascertain what task and responsibilities she could be assign or be accountable and take responsibility to ensure that the patient was being monitored in a timely manner and proper recording was done.'Care not documented is care not done' therefore Nurse Smith could not say the blood pressure was done because there was no evidence of it.
My experience in a situation regarding proper record keeping took place whilst i was assigned to the A&E dept.A patient was seen by the triage Dr. and was given initial treatment and diagnostic evaluation were done.The patient was to be review when the results of the test were available however the patient went home  although he was told that he would  be reviewed when the results were available.He came back the following day with severe anal hemorrhaging and died soon after.However proper documentation was done to prove that the patient was informed that he was to be reviewed when the results were available, the time the results were available,the amount of times the  patient was called by the reviewing DR.without any response and the date and time for each call.The Dr. further made notes that he tried contacting the patient  to no avail
hence no one could be held responsible for negligence.

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Nurse Smith did not uphold the code in effective record keeping. He reasoning is that she was busy and short of staff. this sometimes we are faced with and it is sometimes easier to delegate task to junior staff members in order to get the work done. Nurse smith in her statement says she though the student nurse knew who to give the medication to and how hard should it be. th

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It is rather evident that Nurse Smith did not adhere to the principles of record keeping.Based on the statement Nurse Smith  provided she took  no responsibility for any acts. When delegating the Nurse had to ensure that the instructions given was clear and the student was competent to carry out the task.
Her statement does not provide the  date and time the incident occurred. It was event that recording keeping ,handling and  storage of recorded have been overlooked as the patients initial vital sign on admission was not accessible or not documented.Inadequate records was done as the statement by Nurse Smith does not entail evidence of the patient under continues monitoring as no vitals or GCS of the  patient was documented.

In my practice i ensure that  documentation is accurate, dated, signed,  complaints or words voiced by the patient and actions taken as a result of a complaint is recorded.
Reading this  module was a reminder for me in spite of rendering care can be overwhelming as a result of being under staff that "The excuse of being too busy to maintain adequate records provides no defense against litigation." (wood , 2010)

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The principles of record was not applied as there was no documentation of the patient status. After a breach in Care that resulted in an error the task of monitoring this patient should not have been delegated to the student nurse. The nurse should monitored this patient and look carefully to identify any foreseeable harm. The student nurse again failed to document the observations which made her and the nurse liable because she is answerable to the profession self, patient, institution and practice and should know what task can be delegated in This situation the monitoring  should have been done by the nurse.
My personal experience from practice of poor record keeping was when I received a patient with Maidstone infusion that was not documented in the flow sheet I immediately had to inform the physician and a session was made to disclose the i formation to the patient write an incident report and monitor patient for effects of the amiodarone. No harm came to the patient.

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According to the scenario, Nurse Smith did not follow all the principles of good record keeping according to the NMC (2015). The Code. The record was not dated and no time was included as to when the events occurred.  There was no documentation of care given, no vital signs on admission, and no vital signs after the event occured. The record was not accurate. How often the patient was being monitored. It did not detail the condition of the patient before the event occurred.

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An accurate written record outlining all aspects of patient care and monitoring is important to show nurses management of their patient because nurses are held accountable for actions taken and not taken.So clear, accurate timely, factual and consistent information should be document, to support clinical judgement and decision made.
In the scenario regarding RN smith none of the principles of recording was adhere to as their was no accurate documentation of events that occurs regarding medication error that occur as a result of the student mistakes. Actions taken after the incident was not identify, and vitals signs monitoring upon admission and during care omitted or not carried out. The patient was not informed and nurse smith did not take any responsibility for her actions or inaction regarding the situation and care of the patient.
In my practice accurate timely, clear factual documentation is of paramount importance to keep up with the standards of my organisation, and professional regulatory body and to provide evidence of care delivered and actions taken, in the event of legal actions that may arise as a result complains that may arise.

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                                        Recording  keeping statement:- A nurses’s documentation should be timely and accurate. It should prove that a comprehensive nursing assessment of the patient has been undertaken and should also include care that has been planned and provided. Nurses are professionally accountable for ensuring that any duties they delegate to unregistered staff are undertaken to a reasonable standard eg. if a nurse delegates record keeping to a student, he /she must ensure that the student is capable of carrying out the tasks and is adequately supervised. The nurse is accountable for those records and such entries must be clearly countersigned. The student was expected to perform to the best of her level of nursing education and competence  but the accountability rested on the nurse since she was the delegator and was also acting in the capacity of the student’s preceptor. Vital information was missing from the patient’s record such as his admitting BP, then        there were gaps in the observations recordings for a 30min- period. According to the law” not documented , not done.” The nurse can be charged with misconduct. She seemed to be placing the blame solely on the student, and not being accountable.There was suspected fragmentation or discontinuity of care, meaning a pause in the observations , while the student was on her break. If indeed the observations weren’t continued for that period, then that could be regarded as abandonment of the patient. The failure of documentation was a breach in the duty of care. Additionally, she failed to ensure that the tasks she delegated were  within the student’s level of competence and that she could safely perform.  The nurse based her decision on her assumptions/ opinion and the student was not appropriately supervised.

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                                        Recording  keeping statement:- A nurses’s documentation should be timely and accurate. It should prove that a comprehensive nursing assessment of the patient has been undertaken and should also include care that has been planned and provided. Nurses are professionally accountable for ensuring that any duties they delegate to unregistered staff are undertaken to a reasonable standard eg. if a nurse delegates record keeping to a student, he /she must ensure that the student is capable of carrying out the tasks and is adequately supervised. The nurse is accountable for those records and such entries must be clearly countersigned. The student was expected to perform to the best of her level of nursing education and competence  but the accountability rested on the nurse since she was the delegator and was also acting in the capacity of the student’s preceptor. Vital information was missing from the patient’s record such as his admitting BP, then        there were gaps in the observations recordings for a 30min- period. According to the law” not documented , not done.” The nurse can be charged with misconduct. She seemed to be placing the blame solely on the student, and not being accountable.There was suspected fragmentation or discontinuity of care, meaning a pause in the observations , while the student was on her break. If indeed the observations weren’t continued for that period, then that could be regarded as abandonment of the patient. The failure of documentation was a breach in the duty of care. Additionally, she failed to ensure that the tasks she delegated were  within the student’s level of competence and that she could safely perform.  The nurse based her decision on her assumptions/ opinion and the student was not appropriately supervised.

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The principles of record keeping as stated in section 10 of the Code, were not applied in the case of RN Smith. There was no documentation of the patient's vital signs on admission. The patient may have been admitted by another nurse, however if proper documentation had taken place the relevant information would have been available when needed for continuity of care. Additionally, proper documentation was not done during the observation of the patient. There is no evedence that the staff nurse assigned anyone to take over the observation of the patient while the student nurse went on her lunch break so the patient was left unattended, hence no documentation for 30minutes.

In relation to my practice, one incident that  comes to mind, was a patient who was discharged from my unit. He did not keep his follow up appointment and claimed that he was not informed, however on review of his records, discharge teaching was conducted in respect to his take home medication and follow-up appointment and everything was documented in detail therefore the nurse could not be held liable. All because of proper documentation.

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 Scenario: Staff Nurse SmithStaff Nurse Smith did not follow the principles of recording. Based on staff response there is no evidence of patient’s v/s signs being documented on admission or when monitoring was done after the medication incident.There seems to have been a breakdown in communication between staff and student. The student left the patient to be monitored and went to lunch, there is no indication that a hand over took place for continuity of care.There is no recording indicating that the patient was informed of the incident that occurred, the need for continuous monitoring and also the need for patient to report expected/unexpected signs and symptoms to nurse.In my opinion staff needs to assess her students, know their strengths before delegating tasks. If staff Smith continues that trend she will jeopardize her own practice

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 Scenario: Staff Nurse SmithStaff Nurse Smith did not follow the principles of recording. Based on staff response there is no evidence of patient’s v/s signs being documented on admission or when monitoring was done after the medication incident.There seems to have been a breakdown in communication between staff and student. The student left the patient to be monitored and went to lunch, there is no indication that a hand over took place for continuity of care.There is no recording indicating that the patient was informed of the incident that occurred, the need for continuous monitoring and also the need for patient to report expected/unexpected signs and symptoms to nurse.In my opinion staff needs to assess her students, know their strengths before delegating tasks. If staff Smith continues that trend she will jeopardize her own practice

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Principles of Record Keeping

Timely and accurate entry should be maintained.
Written in a way that can be understood by others and by extension the patient in case of access.
Should support effective clinical judgement and decision making.
Should support clinical audit and research.

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Principles of Record Keeping

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The onus in on all charge/staff nurse to ensure all documentation are in chronological order with clear and concise relevant content as it relates to the patient's condition. An error took place, it was Nurse Smith's duty to document the incident, take corrective actions and inform relevant personnel of the incident e.g. (attending physicians, patient, relatives and nursing office). It was also her duty to delegate close monitoring of the patient to herself or another trained staff who can be able to identify a change in the patient's condition.

Taking responsibility or being accountable for all actions taken under Nurse Smith's purview is her largest flaw and weakness. Accountability enables responsible actions and vigilant monitoring to ensure safety for the patient.

In my setting/practice we are governed by standards of operations which guides us through our practice. A breakdown in not adhering to these practices leads to errors and impaired safety of our clients. To be honest, we lack in some areas of the principles governing record keeping as adhering to international standards are not always forthcoming. Many people do not like change and some refuse to adopt.

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10 Keep clear and accurate records relevant to your practice

This applies to the records that are relevant to your scope of practice. It includes but is not limited to patient records.

To achieve this, you must:

10.1 complete all records at the time or as soon as possible after an event, recording if the notes are written sometime after the event

10.2 identify any risks or problems that have arisen and the steps taken to deal with them so that colleagues who use the records have all the information they need

10.3 complete all records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements

10.4 attribute any entries you make in any paper or electronic records to yourself, making sure they are written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation

Staff Nurse Smith in her statement took no responsibility for any action.  It is evident from her statement that the record had missing data relevant to the patient before the administration of the drug.  She then delegated the task to the junior nurse who made the error with the medication, her notes don't reflect that the patient was informed of the incident and the complications that may arise. She did realize that the nurse gave the wrong medication and did call the physician.  Although she delegated the task she didn't specify that understood her instructions clearly. Her record states her opinion of the situation.

As this relates to my practice, good record keeping is of paramount importance and as a clinical instructor, I ensure that nurses' documentation is that of the institution standard and adheres to its policy and guidelines for documentation.  Documentation of a medication error will include all steps taken which include:

Patient notification
Patient vital signs
Physician notification and orders
Relatives notified
Any medication administered
Notification of nursing office verbally and in writing
A written report of actions taken and responses