End of Life Care Co-ordination and Record Keeping

Discussions and planning with people about their preferences and choices about dying are extremely sensitive. The process is a continuous dialogue between the individual and those close to them. By improving the recording and communication of people’s wishes and preferences for their end of life care, you are able to plan for their general care, as well as anticipate needs for the future. Record keeping should be in a consistent way to support communication between teams. Planning a good death helps to maintain quality of life until the end.

Mental Capacity and ‘best interest’ decisions

The capacity for an individual to make decisions towards the end of their life may be difficult, and by law you need to make every reasonable effort to try to support them to make decisions about their care. However, there may be a time when they lack the mental capacity to make these decisions. At this time you need to look at what provisions, if any, they have in place for another individual(s) to take over this responsibility.

You need to ask the person the following question: “In the event of you being too sick to speak for yourself, who would you like to speak for you?” and then ask: “Have you spoken to that person?”. You need to check that the person who will be making decisions on their behalf, fully understands what this means.

Your Responsibility

You have a responsibility to provide accurate records and update/amend these records and/or notify an individual when a change needs to be made.

Even more crucial is that these records remain confidential, and should not be shared with others unless permission is given. For instance, if family members request access to these records then you need to check they have permission to look at these.

Principles of record keeping

The overall principles of record keeping, whether you are writing by hand or making entries to electronic systems, can be summed up by saying that anything you write or enter must be honest, accurate and non-offensive and must not breach patient confidentiality. If you follow these four principles, your contribution to record keeping will be valuable.

More specifically, you should always try to ensure that you:

  • hand write legibly and key-in competently to computer systems
  • sign all your entries
  • make sure your entries are dated and timed as close to the actual time of the events as possible
  • record events accurately and clearly – remember that the patient/client may wish to see the record at some point, so make sure you write in language that he or she will understand
  • focus on facts, not speculation
  • avoid unnecessary abbreviations – as you’ll find, the health care system uses many abbreviations, but not all workplaces use the same definitions: for instance, ‘DNA’ means ‘deoxyribonucleic acid’ in some places, but ‘Did Not Attend’ (meaning a patient/client who does not show up for an appointment) in others – avoid abbreviations if you can.
  • record how the patient/client is contributing to his or her care, and quote anything he or she has said that you think might be significant
  • do not change or alter anything someone else has written, or change anything you have written previously; if you do need to amend something you have written, make sure you draw a clear line through it and sign and date the changes
  • never write anything about a patient/client or colleague that is insulting or derogatory.

When you’re writing, always follow the principles described in the section written communication and remember, if you find something you feel is significant when you are working with a person, your first duty is to report it to the registered nurse in charge before you would consider writing it in the patient’s record. Always report first, record later.

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