Extending Independent Nurse Prescribing within NHSScotland
NURSING RECORDS
Noting prescribing in the nursing record: good practice
All nurses are required to keep contemporaneous records, which are unambiguous and legible. The NMC Guideline for Records and Record-Keeping 8 outlines the requirements of nurses' records. The record of the nurse or midwife's prescription should be entered into the nursing patient record (where a separate nursing record exists e.g. in hospitals) at the time of writing. The prescription, together with other details of the consultation with the patient, should be entered into the general (GP or hospital) patient record as soon as possible and preferably contemporaneously. It should be marked to indicate that it is a nurse or midwife prescription and should include the name of the prescriber. The maximum time to be allowed between writing the prescription and entering the details into the general record is for local negotiation, but best practice suggests that this should be immediately. Only in exceptional circumstances should this period exceed 48 hours from writing the prescription. Arrangements for the sharing of all relevant patient records can be put into locally agreed statements of good practice. Where practicable, electronic records should be used, and prescriptions should be generated via these systems.
It is recommended that the record clearly indicates the date, the name of the prescriber, the name of the item prescribed, formulation and the quantity prescribed (or dose, frequency and treatment duration). For medicinal preparations, items to be ingested or inserted into the body, it is recommended that the name of the prescribed item, the strength (if any) of the preparation, the dosing schedule and route of administration is given e.g. 'paracetamol oral suspension 120mg/5mls, 5mls to be taken 4 hourly as required for pain, maximum of 20mls in 24 hours'. For topical medicinal preparations, the name of the prescribed item, the strength (if any), the quantity to be applied and frequency of application should be indicated. For dressings and appliances, details of how to be applied and how frequently changed are useful. It is also useful, but not mandatory, to note advice given on over-the-counter items.
In some circumstances, in the clinical judgement of the nurse or midwife prescriber, it may be necessary to advise the GP or consultant immediately of the prescription. This action should be recorded in the nursing records.