Once a bit of time had passed after my mum died in February (a terrible end of life experience for her and the family, some of it blogged here), I asked for her notes. I wanted to see how she had been cared for in a professional sense. I wanted to see the decision making, the prescribing, the carrying out of care. I wanted to know who had cared for her, who had assessed her need for nursing, who had signed off nursing interventions, who had recorded her care.
I filled in the form, paid my £10 and duly received a 3 inch pile of paper. 0.1 inch of the papers were the medical notes. Handwritten but largely legible, dated and signed, succinct, little diagrams where necessary. Referrals noted with date and time, and followed up with results. OT visits and assessments were written in the medical notes. Physio assessments and instructions were written in the medical notes. Social worker visits were recorded in the medical notes. A clear, chronological narrative of those aspects of Mum’s care.
The other 2.9inches of the papers consisted of charts and forms. TPR/BP charts. Bowel charts. Fluid balance charts. Prescription charts. Fall assessment forms, done on admission and never reviewed. Pressure area assessment forms, filled in on admission and never repeated. Something called an ‘observation form’, only filled in when Mum was deemed to need ‘observing’ (but in 7 weeks of hospitalisation there were pages and pages of them). Some entries readable, many illegible. Some barely literate, appalling spelling, laughable grammar. Scribbled and unidentifiable signatures. Often no indication of the level or grade or even the profession of the person who had filled in or signed them. Not always dated, rarely timed. Finding a nursing narrative of Mum’s care was impossible. I read and cross-referenced and pieced bits of paper together to try to work out what had happened, when. Even then it was fragmented, incomplete and uninformative. There was no sense of the progression of Mum’s nursing care and treatment, no reviews, no judgements or prescribed interventions. I had no idea how anyone new to Mum would know what she needed shift by shift. It was a shocking indictment of what passed for nursing on that ward. Fill in the chart. Tick the box. All that was done. Yet she fell, harmed herself in her confusion, developed a grade three pressure sore, was severely dehydrated and malnourished, cried out in pain. But all the boxes were ticked, the charts completed.
What has nursing come to?
Please use this as a case study for students. To impress upon them that the documentation is important, but it isn’t care. It’s only worthwhile if it’s literate, descriptive and chronological – and even then, it’s not nursing. Mum’s nursing documentation was embarrassing in the poverty of its description, in its illiteracy, in its lack of meaning. I’ve heard nurses chant with pride – ‘If it’s not documented, it’s not done’. Well, let me tell you – when it’s documented sometimes it’s not done either. On that ward someone, everyone, had badly missed the point.