Accurate record keeping - health and care professionals take note

The Administrative Court has dismissed the appeal by a nurse against a decision of the Conduct and Competency Committee of the Nursing and Midwifery Council in Marten v Nursing and Midwifery Council QBD (Admin).

The case was concerned with dishonesty - inaccurately recording a patient’s heart rate knowing that it was wrong. The decision of the judge is a salutary reminder to all health and care professionals of the importance of accurate record keeping.

The nurse in question had worked in a paediatric intensive care unit. Another nurse, relieving her from the day shift, raised concerns about the previous reading’s accuracy.

Two charges were brought against the nurse. In summary:

• making inaccurate records, and
• doing so dishonestly.

The NMC’s conduct committee found that both charges were proved and that the nurse had made the records based on visual assessment of the patient as opposed to a physical examination.

At appeal the judge found that, given the importance of accurate record keeping, it was obvious that a reasonable and objective person would consider the nurse’s actions dishonest.

The importance of accurate record keeping should not be underestimated. While the primary function of nursing records is to aid communication between healthcare professionals and a patient the purpose of medical records is to also provide a clear and precise clinical account of the patient’s healthcare journey and reflect the practitioner’s assessment, planning and evaluation processes. The NMC’s Code of Practice for its registrants sets out a nurse’s obligation to keep clear and accurate records.

If you require assistance with your policies and practice or training on what good note keeping looks like do get in touch.