recording care: evidencing safe and effective care

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!