-1East of England Neonatal Benchmarking Group
Benchmark: Record Keeping
Score relates to practice in (unit):
Lead EOENBG member for the unit:
Date to be scored:
--/--/--
Scored by:
Date scored:
Date of next meeting to share good
practice and compile action plan:
Copies:
Y/N
--/--/-Re-score date agreed:
-- / -- / --
--/--/-Standard:
"All professionals should make clear and adequate notes. The standard should be that
which enables a colleague coming new to the case to be properly informed"1
"Record keeping is an integral part of nursing and midwifery practice, not separate from
this process and not an optional extra to be fitted in if circumstances allow"2
Definition: Record
An account in permanent form preserving knowledge or information
A written account which serves as legal evidence
Collins English Dictionary (1987)
Highest level of evidence used3 = IV
Assessment: Nursing records of infants within the neonatal unit
Drivers for the development of the benchmark
Department of Health - Essence of Care4
NMC:Guidelines for Records and Record Keeping2
CESDI Report 19991
Documentation
Audit
Education
NMC: Code of professional conduct 20025
Criteria for Scoring

Total of 6 infants (inborn infants only)

Period of 1 week
KEY FACTORS
F:1
F:2
F:3
F:4
F:5
Individual
scores
An audit of record keeping is undertaken
annually
Content and style
Legal Matters, Risk Management &
Confidentiality
Parent/Professional Relationship
Communication and Information sharing
Overall Score
Original version
2nd Version agreed
3rd Version agreed
November 2001
October 2004
February 2006
4th Version agreed
5th Version agreed
Next review due
EOENBG Record Keeping Benchmark 5th Version – October 2010
Possible
total
3
12
8
6
3
32
August 2008
October 2010
October 2011
-2-
FACTOR 1: An audit of record keeping is undertaken annually
Audit can play a vital part in ensuring the quality of care that is delivered and this
applies equally to the process of record keeping. By auditing your records, you
can assess the standard of the records and identify areas for improvement and
staff development.2
Criteria for Best Practice
1. All records will be audited using a record keeping tool6
2. There is evidence that action has been taken as a result of the audit
3. Audits should be undertaken annually7
There is no
documentation
audit tool
(Related to criteria above)
Score 1 for every criteria met and
justify.
0
1 -2
There is
evidence of an
annual audit and
documented
action has been
implemented
3
Factor 1: An audit of records are undertaken annually
SCORE
3
Statements to justify score:
EOENBG Record Keeping Benchmark 5th Version – October 2010
-3-
Factor 2: Content and Style
Record Keeping should be able to demonstrate a “full account of your
assessment and the care you have planned and provided” 2,8,9
“Details should be recorded of any assessments and reviews undertaken and
provide evidence of the arrangements made for future and ongoing care”2
Criteria for Best Practice
Records are written in accordance with the NMC guidance on record keeping,
measurable by:
1. Name and unique identifier number on every page
2. Date and time all entries6,9
3. Signature and professional designation (first signature followed by printed
name)6,9
4. All entries written in indelible black ink6
5. Corrections should be made a single line initialed, dated and time
6. Space left to the end of the line blocked off
7. Entries made by non registered are countersigned by a nurse qualified in
the specialty
8. All entries are legible to the reader8
9. Only Trust approved abbreviations used
10. Written in chronological order as soon as possible after the event9
11. Record is factual, consistent and accurate
12. Notes should not be written in retrospect and if written in retrospect
should be stated1.
(Related to criteria above)
Records meet none
of the NMC criteria
Score 1 for every criteria
met and justify.
0
Records meet all 12
NMC criteria
1 - 11
Factor 2: Record Keeping – content and style
SCORE
12
Statements to justify score:
EOENBG Record Keeping Benchmark 5th Version – October 2010
12
-4-
Factor 3: Legal Matters, Risk Management and Confidentiality
“All NHS bodies have a common law duty of confidentiality. Personal information about
patients held by health professionals is subject to a legal duty of confidence and should
not be disclosed without the consent of the 'subject'. Imparting any information without
the consent of the subject would be breach of confidence” 10,11
The content of the record demonstrates inclusions, which permit a full understanding of
events that have occurred and retrospective analysis of care delivered2
Remember that in a court of law 'if it is not recorded, it has not been done'
12
“Records should identify any risks or problems that have arisen and show the actions
taken to deal with them”2
Criteria for Best Practice
1. Provides accurate information on the condition, care and treatment of the
patient6,13,14,15
2. Records the chronology of events and the reasons for any decisions
made16
3. Infants’ records demonstrate that their care and treatment follows
evidence-based guidance or supporting documents describing best
practice, or that there is an explanation of any variance
4. Infants’ records demonstrate that where necessary local guidelines
relating to risk management have been followed and critical incidents
reported17
5. The record includes identification of equipment used with asset numbers18
6. Staff must be aware of responsibilities to maintain confidentiality
according to Trust policy19.
7. There is a local Trust policy relating to parent access to their infants’
record20,21.
8. Patient records should not be left unattended at any time22,23 and the
detail contained must be protected from public view
The record
provides no
information about
the infants care or
risk issues.
Score 1 for every criteria
met and justify.
0
1-7
(Related to criteria
above)
The chronology of events
is a true account of the
care delivered, the record
is stored safely and risk
issues are addressed.
SCORE
Factor 4: Factor 3: Legal Issues/Risk Management &
Confidentiality
8
Statements to justify score:
EOENBG Record Keeping Benchmark 5th Version – October 2010
8
-5-
Factor 4: Parent/Professional Partnership
Parents must be given information to enable them to participate in their infant’s
care24
Criteria for Best Practice
Within the record there is evidence of the following:
1.
2.
3.
4.
5.
Individualized parent education.
Parent/professional discussions have taken place and recorded.
Areas of concern are highlighted and documented where they exist.
Any written information given to the parents is recorded
There is an opportunity for the parents to contribute to the record /
charts, in partnership with staff according to local policy
6. Activities that the parents undertake with their baby are recorded.
The record shows
no evidence of
parental
involvement
(Related to criteria above)
Score 1 for every criteria
met and justify.
0
SCORE
1-5
There is evidence that
the parents are
empowered through
education &
professional support to
interact with & meet
the needs of their
infant.
6
Factor 4: Parent/Professional Partnership
6
Statements to justify score:
EOENBG Record Keeping Benchmark 5th Version – October 2010
-6-
Factor 5: Communication and Information Sharing across
Professional and Organisational Boundaries
“Health care professionals responsible for the care of any particular patient must
communicate effectively with each other. The aim must be to avoid giving the
patient conflicting advice and information.”24
‘The need to ensure that all services to children and their families are firmly
centred on the carefully elicited needs and wishes of the children themselves.
To ensure that child protection service provision and expertise is
commensurate with the scale and impact of child maltreatment in the UK25
Record keeping is an invaluable way of promoting communication within health
care2
Criteria for Best Practice
1. Members of the multi-professional team involved in the care and
treatment of the infant must be clearly identifiable from the record
2. Actions relating to an infants care and treatment must be documented in
the nursing records26.
3. Timely referrals to other professional disciplines are made to meet the
infants’ needs and parents are made aware. These are dated,
documented and actioned.
There is no evidence
of information
sharing between
members of the
multidisciplinary
team.
0
SCORE
(Related to criteria above)
All relevant
information is shared
& documented by
the multidisciplinary
team.
1-2
3
Score 1 for every criteria
met and justify.
Factor 5: Communication and Information Sharing
3
Statements to justify score:
EOENBG Record Keeping Benchmark 5th Version – October 2010
-7-
References:
1. CESDI (1999) 6th Annual Report: Maternal and Child Health Research
Consortium, London. [IV]
2. NMC (2009) Guidelines for records and record keeping. Nursing & Midwifery
Council, London. [IV]
3. National Institute for Clinical Excellence (2001) The Use of Electronic Fetal
Monitoring Inherited Clinical Guideline C, May, London. [IV]
4. Dept. of Health (2001) The Essence of Care Patient-focused Benchmarking for
health care practitioners www.doh.gov.uk/essence of care/index.htm [IV]
5. NMC (2008) Code of Professional Conduct. Nursing & Midwifery Council,
London. [IV]
6. Cowan J. (2000) Clinical governance and clinical documentation: still a long
way to go? British Journal of Clinical Governance. 5(3):179. [IV]
7. NHS Litigation Authority (2004) CNST Maternity Clinical Risk Management
Standards. NHS Litigation Authority [IV]
8. Tingle J H (1999) Nurses are accountable for their records. British Journal of
Nursing 8(11):701. [IV]
9. Glover D. (1999) Keep your record clean. Nursing Times. December,
1;95(48):26. [IV]
10. Dept. of Health (2001) The Essence of Care – Record keeping
www.doh.gov.uk/essence of care/index.htm. [IV]
11. Dept. of Health (1996) The protection and use of patient information:
Guidance from Department of Health. DoH. London. [IV]
12. Cudmore J. (2000) Write it down, for everyone's sake. Nursing Times. March
9;96(10):26. [IV]
13. NHS E (1999) Clinical Governance in the new NHS Health Service Circular
1999/065 The Stationary Office London. [IV]
14. CESDI (1999) 5th Annual Report: Maternal and Child Health Research
Consortium, paragraph:9.4. London. [IV]
15. CESDI (1999) 3rd Annual Report: Maternal and Child Health Research
Consortium, paragraph:9.3.10. London. [IV]
16. Chapman GF. (1999) Charting Tips: Documenting an adverse incident.
Nursing. February;29(2):17. [IV]
17. National Patient Safety Agency (2002) Reporting Incidents: Draft guidance
issued. www.npsa.org.uk/static/reporting.asp [IV]
EOENBG Record Keeping Benchmark 5th Version – October 2010
-8-
18. MDA. (1993) The report of the expert working group on alarms on clinical
monitors: in response to recommendation 11 of the Clothier Report (The Allitt
Inquiry). [IV]
19. Data Protection Commission (1998) Data Protection Act LASSL(98)16
www.dataprotection.gov.uk [IV]
20. NHSE (1991) Access to Health Records Act (1990): A guide for the NHS. [IV]
21. Freedom of Information Act (2000)
22. NHS Litigation Authority. (2005) CNST Clinical Risk Management. Standard 4:
Health Records. [IV]
23. Dept. of Health. (1999) Managing Health Records. [IV]
24. Bristol Royal Infirmary Inquiry (2001) Learning from Bristol: The report of the
public inquiry in to children’s heart surgery at the Bristol Royal Infirmary
1984-1995. Command Paper CM 5207. www.bristol-inquiry.org.uk [IV]
25. Laming, Lord. (2003) The Victoria Climbe inquiry: www.victoria.climbeinquiry .org.uk/finereport/finport.htm [IV]
26. Pincock S. (2004) Poor communication lies at heart of NHS complaints,
says ombudsman. BMJ. 3 January;328(10)doi:10.1136. [IV]
Bibliography:
Castledine G (1998) The blunders found in nursing documentation. British
Journal of Nursing. Oct 22- Nov 11;7(3):1218 [IV]
Castledine G (1998) The standards of nursing records should be raised. British
Journal of Nursing. February 12-25;7(3):172. [IV]
Culley F (2001) The tissue viability nurse and effective documentation. British
Journal of Nursing. August;10(15 Suppl):S30-9. [IV]
Dimond B (1995) (2nd ed.) Legal Aspects of Nursing Prentice Hall London. [IV]
Tingle J H (1998) Nurses must improve their record keeping skills. British Journal
of Nursing. March 12-25;7(5):245. [IV]
Kerr CM, Lewis DM. (2000) Factors influencing the documentation of care.
Professional Nurse. May;15(8):516-519.
Davies M. (2000) Improving documentation. Professional Nurse.
February;15(5):296. [IV]
EOENBG Record Keeping Benchmark 5th Version – October 2010