Background Rheumatology nurse practitioners provide advice, support and information via a telephone helpline. Patients, carers and health professionals access this service. The U. K. C. C. (1998) states that record keeping is an integral component of nursing and should reflect an accurate account of care given.
Objective An audit was undertaken to discover whether the written documentation of the telephone helpline was recorded satisfactorily.
Method A retrospective audit of all calls logged over a three- month period was analysed. The forms were examined to determine if they met the following standards. The date, time and who called should be noted. The nature of the call and the advice or information given should be recorded. All entries should be legible and signed.
Results 393 calls were received over a three-month period. Of these 122 (31%) were medication queries, 67 (17%) treatment inquires, 8(2%) requests for a sooner appointment, 74(19%) questions regarding appointment, 28 (7%) required advice about disease flare up, 35 (9%) test results, 24 (6%) received reassurance and support. There were 4 (1%) enquires about Disability Living Allowance and 31 (8%) concerning other queries.
On all forms the date was recorded in 97%, time 60%, details of who called 99% and type of call 26%. The entries were signed legibly in 95% and written comments were legible in 78% of cases. In 5% of forms the written information was unclear and poorly documented.
Discussion This audit highlighted several problems with the existing documentation. Space was insufficient to record all details, urgent calls needed to be identified and an additional section was necessary for calls that could not be answered immediately. As a result a new documentation sheet has been designed.
The importance of accurate, written documentation is vital in today’s health care and good quality record keeping improves communication and demonstrates evidence of good practice
United Kingdom Central Council for Nursing, Midwifery and Health Visiting. Guidelines for Records and Record Keeping, London, 1998
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