the nursing associate speculated and fails to consider facts. Gambling could mean that there is a 50% chance that the conclusion drawn is correct. This means that there is also a 50% chance that the conclusion drawn is incorrect; therefore, all records must be maintained factually and not speculatively. Similarly, speculation could mean ‘to assume’. Just because a person appears a certain way, an assumption must not be drawn. Again, records must deal in facts only. The next requirement of the NMC Code that relates directly to record‐keeping discusses secure storage.
Safe Storage
Section 10.5 of The Code states that all nursing associates must take all steps to make sure that records are kept securely. Whether a record is made and stored electronically or by hand, the requirement and expectation regarding storage is the same. Firstly, computerised records will generally be stored securely, and the backup of such documents will be automated by an IT department so that the final security and integrity of a record is maintained on the whole without the nursing associate having to be concerned with safe storage of the record. Safe storage also concerns access to records, and the nursing associate is accountable and responsible for any actions or omissions. With regards to safe storage, many computers have a lock screen which automatically engages after a set period of time that the computer is idle. This set time varies from computer to computer but could be as little as a couple of minutes to 15 minutes. In this time, anyone could access the computer if the lock screen has not been manually or automatically engaged and affect the safe storage and integrity of records. The process of manually engaging this lock screen is usually quite straightforward but will mean that the nursing associate will then need to log in to the device again, ensuring that the security of the records has been maintained by limiting access.
Orange Flag
The content of the record was inflammatory and accusatory; the ward clerk was clearly upset by what she was reading.
The negligent action caused by the nursing associate in failing to log off from the workstation caused psychological harm to the ward clerk who was clearly distressed by what she had read. What action should be taken next?
When considering safe storage of manually made records, it is the nursing associate who is accountable for ensuring that the record that they are accessing and making an entry in is returned to its safely stored position that it was in before it was used. Some records will be stored at the patients’ bedside or in their own home, but other records will be stored centrally in the clinical area. It is crucial that the nursing associate considers the record that is being accessed and stores it appropriately thinking again about how limited the access to the record needs to be.
Take Note
Finally, in Section 10, nursing associates are reminded to collect, treat and store all data and research findings appropriately. While many nursing associates may not consider themselves to be part of a research team, much of the data that is recorded during day‐to‐day work could be used as valuable data in a research project. When considering data being used as part of a research project, the project will have been granted ethical approval from the organisation overseeing the study. This ethical clearance will include clarification of how data will be gathered, collected, stored, analysed and reported. Whether acting in the capacity of a data collector or indeed the researcher, it is imperative that the nursing associate follows the guidelines set in the research proposal that has been analysed by the relevant ethical body. What is very important to consider in this section is that often data is accessed retrospectively. If a research study, for example, was being conducted into whether turn charts were effective in the prevention of pressure ulcers, the researcher may look at records relating to previous admissions where patient outcomes are already known. This puts an onus on nursing associates to ensure that all records are clear and accurate as all records could potentially form part of a research study. This final requirement has so many close relations with the other requirements of section 10 of The Code (2018a) that it clearly demonstrates how important record‐keeping is professionally.
Having considered record‐keeping from a professional perspective and addressed all the aspects described in The Code (2018a), it is clear to see that record‐keeping should be fundamentally straightforward; however, there are many strands to record‐keeping that are so intertwined that it is difficult to do one without the other. For example, to keep a clear record, it has to be legible, dated, timed and so on. In the next part of this chapter, the legal perspective will be addressed in an attempt to demonstrate that the reason nursing associates have to keep clear and accurate is that a number of different Acts and pieces of legislation may require records to be scrutinized.
From a Legal Perspective
This chapter cannot attempt to compete with the many texts that have been written on the legal duties of a nurse. See Table 8.1 for an overview of some elements of legislation that impact on record‐keeping.
Table 8.1 Some aspects of legislation that impacts record‐keeping.
| ASPECT OF LEGISLATION | DISCUSSION |
|---|---|
| Access to Health Records Act (1990) | This relates to records of deceased patients since 1 November 1991; however, access is only allowed if the record would not cause harm to any living person. |
| Access to Medical Reports Act (1988) | Allows individuals to apply in writing to access their health records and then allows patients to disagree with a report or to correct any inaccuracies; however, access can be denied by a doctor if they feel that the record could harm the individual or that the record also has information relating to a third party who has consented to the release of the record. |
| Civil Evidence Act (1995) | This Act allows the use of records as evidence in civil legal proceedings |
| Computer Misuse Act (1990) | This Act created three separate offences. The first is the unlawful access of computer records, the second is access with the intent to commit further offences and the third is the unauthorised modification of computer materials. |
| Data Protection Act (1998) (updated in 2018) |
The Data Protection Act regulates how personal data is processed regardless of how it is stored, i.e. manually or digitally. Processing data includes how a record is stored, obtained, recorded in the first instance, used (including disposal), disclosed and shared. Eight principles underpin this Act. The Data Protection Act was updated in 2018 to include General Data Protection Regulation (GDPR) standards from the European Union. The Act was updated to ensure that the law was fit for the digital age and the ever‐increasing amount of personal data that is being generated and being
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