Proof of the partnership

Mental Health Nursing,  Jan 2003  by McGreevy, Pat

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Client held records are a good idea and occasional headaches should not block the way to full implementation, says Pat McGreevy

As someone who has banged on about client held records for many years, I am greatly encouraged to read that yet another team has piloted and are implementing this initiative (MHN Nov 2002)

In our team, we too, have just completed a six-month pilot with newly referred clients. The initial findings suggest that most clients are very satisfied with retention of their records and that nurses are pleased with the prospect of having many of their records fully up-to-date every day. Clearly, however, a smaller number of clients do not want to retain their records. A formal evaluation of this pilot is now underway.

I am heartened that the team, reported in last issue, has moved to institutionalise the client held record initiative into their practice.

I, too, feel that client held records will become an established modus operandi for community mental health nurses in their record making and record keeping. There are, however, still some very important issues as we progress towards widespread implementation. The client held record in the majority of cases must be the main and only record of nurse/client care encounters. But supplementary records will in some situations and circumstances have to be made and kept.

Full informed consent, when sought before this initiative is implemented, must entail fully explaining to clients that there may be occasions when supplementary records are made and kept.

Client held records are tangible proof of the partnership we strive for with clients. They will demonstrate the nurse-client negotiations and sometimes the differing perspectives recorded for both to see and share.

Relevant third party information derived from other professionals would be deposited in the supplementary record and these professionals may need assurances that this will be so and not entered on the client held documents.

I still, passionately, believe that client held records are a powerful therapeutic tool with benefits for clients and practitioners. Where full implementation throws up challenges I see these as hurdles to be overcome rather than permanent blocks. Again, if the service users continue to welcome this initiative they and their representatives will tell us how the implementation challenges can be tackled.

For practitioners seeking to spread the news and the initiative I advocate the development of a client held records network where we could also share the joys and the challenges and smooth the path to full implementation of this proof of our partnership. MHN

Pat McGreevy is chair of the Northern Ireland CPNA and a lecturer practitioner with Down Lisburn Trust

Copyright Community Psychiatric Nurses Association Jan 2003
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