Recording Care: Evidencing Safe and
Effective Care
Professional OfficersSonya McVeigh & Siobhan ShannonBHSCT & NHSCT
Leading Care, Leading Teams – Shaping the FutureWard Sister/Charge Nurse and Team Leader Conference, 17th April 2013
Background Themes Arising from Northern Ireland Public Inquiries
2003 - 2008
Incomplete records through poorly documented:• Admission / discharge arrangements• Risk assessments• Essential monitoring reports• Engagement with family members• Engagement with other professionals
Leading Care, Leading Teams – Shaping the FutureWard Sister/Charge Nurse and Team Leader Conference, 17th April 2013
Recent Context • Public Inquiry into the outbreak of Clostridium
Difficile in Northern Trust Hospitals (2011).3 –Trust Board must review governance arrangements
and satisfy itself that it is meeting in full its responsibilities for patient safety, quality of care and record-keeping.
• Mid Staffordshire Inquiry-Francis Report
• Hypotnatraemia
Regional Record Keeping Initiative (2009/10)(RRKI)http://www.nipec.hscni.net/pw_recordkeeping.htm
Literature Review:
1. Value and Purpose of Record Keeping 2. Audit3. Information Recorded4. Competence to Record5. Professional Supervision6. Patient Awareness/Inclusion7. Issues Related to Time
The Nursing and Midwifery Councilstates:
‘Good record keeping helps to protect the welfare of patients and clients’ (NMC, 2002)
Good record keeping is a mark of a skilled and safe practitioner, while careless or incomplete record keeping often highlights wider problems with that individual's practice.’ (NMC 2007)
Jane Doe
Leading Care, Leading Teams – Shaping the FutureWard Sister/Charge Nurse and Team Leader Conference, 17th April 2013
Recording Care Project 2012 Aim: To implement an agreed Regional HSC Nursing
Document, and improvement methodologies, tools and resources developed during the RRKI to facilitate improvement in the standard of nurse record keeping in Northern Ireland and to promote a culture which supports person-centred record keeping practices.
Leading Care, Leading Teams – Shaping the FutureWard Sister/Charge Nurse and Team Leader Conference, 17th April 2013
Strand 1• Piloting a new
Regional Nursing Assessment & Plan of Care document
• Standards for nursing and midwifery record keeping practice
Leading Care, Leading Teams – Shaping the FutureWard Sister/Charge Nurse and Team Leader Conference, 17th April 2013
Strand 2
Practice Improvement Programme
www.nipec.hscni.net/recordkeeping/
Leading Care, Leading Teams – Shaping the FutureWard Sister/Charge Nurse and Team Leader Conference, 17th April 2013
Leading Care, Leading Teams – Shaping the FutureWard Sister/Charge Nurse and Team Leader Conference, 17th April 2013
Leading Care, Leading Teams – Shaping the FutureWard Sister/Charge Nurse and Team Leader Conference, 17th April 2013
Safer person centred care
Evidenced through improved record keeping practice.
Robust assurance regarding record keeping standards.
For the Person
For the Nurse
For the Trust
Outcomes
Leading Care, Leading Teams – Shaping the FutureWard Sister/Charge Nurse and Team Leader Conference, 17th April 2013
Leading Care, Leading Teams – Shaping the FutureWard Sister/Charge Nurse and Team Leader Conference, 17th April 2013
What’s The Future?• Phase 2
• Mental health, Learning disabilities and Paediatrics
• Potential for movement into the community
• Improvement methodologies implemented
• NOAT amended
Leading Care, Leading Teams – Shaping the FutureWard Sister/Charge Nurse and Team Leader Conference, 17th April 2013
What’s The Future?• E-record developed for acute in-patient
services
• Under 24 hour stay document
• Care-planning explored – development of nursing informatics system
• Launch of Standards document
• Abbreviations policy development
Leading Care, Leading Teams – Shaping the FutureWard Sister/Charge Nurse and Team Leader Conference, 17th April 2013
THANK YOU!