Non medical prescribing in Scotland: implementation guide

Patient records

Access and updating

91. All health professionals are required to keep accurate, legible, unambiguous and contemporaneous records of a patient's care. There is no single model or template for a patient record. For guidance, nursing staff should refer to the standards published by the NMC. ³⁰

92. A good record is one that provides in a timely manner all professionals involved in a patient's treatment, with the information necessary for them to care safely and effectively for that patient. It is a necessary way of promoting communication within the healthcare team and between practitioners and their patients/clients. Good record keeping is, therefore, both the product of effective team working and a prerequisite for promoting safe and effective care for patients.

93. All nurses are required to keep accurate, comprehensive, contemporaneous records which are accessible by all members of a prescribing team (effective policies must be in place locally to enable this to happen). The principles underlying record keeping, for nurses are detailed in national guidelines for records and record keeping ( NMC 2004). ³¹ Specifically in relation to prescribing, nurses should refer to NMC (2006), ³² Practice Standard 7.

94. In supplementary prescribing, the doctor/dentist and supplementary prescribers must share access to, consult and, wherever possible, use the same common patient/client record (see paras 29 - 31).

95. Best practice suggests that the details of any prescription, together with other details of the consultation with the patient, should be entered into the shared patient record immediately, or as soon as possible after the consultation. Only in very exceptional circumstances (e.g. the intervention of a weekend or public holiday) should this period exceed 48 hours from the time of writing the prescription. This information should also be entered at the same time onto the patient record and onto the nursing patient record (where a separate nursing record exists). Where nurse independent prescribers are working in paperless offices and clinics, and there are no paper records, the electronic data must be entered to comply with the aforementioned good practice. In hospital settings, details of every prescription may not be entered separately in hospital medical records but an individual prescription chart is eventually filed in the patient's notes.

96. Where practicable, in both hospital and community settings, electronic records should be used, and prescriptions should be generated via these systems. Nurse independent prescribers may prescribe via computer-generated prescriptions provided the necessary software is available. A visible audit trail of prescribing actions must be maintained however and an existing prescriber's details must never be tampered with. Prescriptions should always be signed immediately, and prescriptions must never be written or printed off and signed in advance, and then stored for future use. See NMC (2006) ³³ Practice Standard 12.

97. Appendix 5 gives guidance on prescription form completion. It is recommended that any prescription record indicates clearly:

• The date of the prescription
• The name of the prescriber (together with the fact that they are acting as a nurse independent prescriber)
• The name of the item prescribed, together with the quantity (or dose, frequency and treatment duration).

98. To aid the safe administration of medicinal preparations the record should include: the name of the item prescribed, the strength (if any) of the preparation, the dosing schedule and route of administration, e.g. 'paracetamol oral suspension 120mg/5mls to be taken every four hours by mouth as required for pain, maximum of 20mls in any 24 hours'.

99. In the case of topical medicines the name of the prescribed item, the strength (if any), the quantity to be applied and the frequency of the application should be indicated. For dressings and appliances, details of how they are to be applied and how frequently changed, are useful. It is recommended that any advice given on General Sale List ( GSL), (also known as 'over the counter') items be recorded.

Clinical Management Plans

100. As referred to in paragraph 31, clinical management plans may still be used by nurse independent prescribers as the most appropriate mechanism for prescribing. The NMC (2006) Practice Standard 8 should be followed in such situations, and the latest guidance issued by the Scottish Executive on 'Supplementary Prescribing for Nurses'.