Notes on nursing (apols Flo)

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.

 

 

9 thoughts on “Notes on nursing (apols Flo)”

  1. Thank you for sharing this June – it must have been heartbreaking reading through your mums medical notes after she was gone. I hate that nursing care has been superseded by documentation. Where is the person centred care in sitting at the nursing station completing endless preprinted care planson usually well patients . Only to find when you really need to know if care was delivered or The notes are not completed because the patient was too unwell and the nurse had no time to complete.

    Think it is time for a rethink – we didn’t go into nursing to follow a medical model of ‘if it’s not documented it didn’t happen’.

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  2. This. This! I find exactly the same in my irregular ward experience. Paper full of assessment forms, sometimes with no name on them even. Lots of boxes ticked. But for me, a new carer, a complete lack of communication of the previous care or current needs. I have reported this, I have sat and explained. And nothing changed. I have seen ward audits that are green when I still can’t find what to do.

    It enrages me.

    As an informatics specialist it enrages me. This has a serious impact beyond the single patient too. No wonder we feel that nursing is becoming less ‘valued’. We don’t even see the importance of documenting the important care we give.

    When we start to look to the data that electronic records give us the chance to record we will be disappointed unless we urgently think about what and how we record information. Where we are today we are likely to be very disappointed.

    It’s time to think carefully about the value we place on information.

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  3. June, your experience chimes completely with my own. For years, I had bemoaned the volumes and volumes of formulaic, meaningless rubbish churned out by nurses in the name of ‘record-keeping’ (https://grumblingappendix.wordpress.com/2013/06/21/the-land-that-time-forgot-is-rethinking-documentation-the-key-to-nursing-reform/). And then it happened to me.

    My husband was diagnosed with extensive cancer. He had sixteen days left to live. When I requested and read his nursing notes, I found the word ‘cancer’ was not mentioned once. Not once. Every crumb of food he ate and every last drop of liquid he drank was fully accounted for (Why? He didn’t have a nutrition problem) and on the meticulously filled-in intentional rounding charts, every visit to the toilet and every minor change of position was diligently documented too – but no mention, at all, of what was actually wrong with him – and what the horrendous implications were likely to be.

    No one comforted him (or me for that matter – but my concern is primarily with him). No one even spoke to him. Why would they? They didn’t even accept that he was ill.

    Before he received his diagnosis, Barry told me that his impression was that the nurses on his ward thought he was malingering. The notes entirely bear that out. Sixteen months on, and I am still so angry about this. How can nurses give appropriate care if they have already made up their minds about a patient before he even receives a diagnosis?

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  4. As a nurse and a daughter, I refused to allow the substandard care my father received in his last month’s of life. No… that’s not right, I TRIED so hard to enforce change to the substandard care. I did not always win the battle and I was appalled that I had to actually request better care.
    My father had an infected pressure ulcer (on top of other things) and was treated with very little respect and dignity for the proud man he had always been.
    I know the value that a kind word or empathic touch can give. It isn’t the completed checklists that my father or our family needed, it was CARE in the truest sense of the word.
    Please, please, please, bring back patient centred care. Bring back the importance of QUALITY CARE.

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  5. Thank you for sharing June. My mum passed away on New Years Day this year peacefully in a local nursing home where she received excellent care. Mums individualised care plan & records were available for us to view daily. During November & beginning of December mum was taken into our local hospital needing IV antibiotics for infected cellulitis. Mum was walking but never walked again. I am not brave enough to request her notes as I don’t think I could cope emotionally with what I may find. A series of tick boxes no doubt but I fear no evidence of true compassionate individualised care.
    My brother & I had to feed mum daily as her tray was often taken away untouched. This was despite constant reminders that her declining mental health (known diagnosis) was effecting her appetite but instead mum was viewed as being difficult. I had to really push hard for a mental health review – staff kept saying it’s not written in the notes. Mum lost a lot of weight and strength during her three week stay.
    True individualised care is what is required that sits along side a set of care pathways. I will be using this blog to share with colleagues in our clinical forum to ensure we’re doing all we are doing all we can to really care.

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    1. It’s so familiar Jo. When I got Mum’s notes I saw that she was on the ‘red jug/tray’ system meaning she needed help and encouragement. We never saw a red jug or tray during her whole stay. I can’t change things for my mum but something has to change for nursing. J

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