Transcript Slide 1
Recording Care: Evidencing
Safe and Effective Care
Professional Officers
Sonya McVeigh & Siobhan Shannon
BHSCT & NHSCT
The Nursing and Midwifery Council
states:
‘Good record keeping helps to protect the welfare of patients and clients’
Good record keeping is a mark of a skilled and
safe practitioner, while careless or incomplete
record keeping often highlights wider problems
with an individual's practice.’ (NMC 2007)
Background
Themes Arising from Northern Ireland Public Inquiries, Official
Reports and Critical Incident Reviews 2003 - 2008
Incomplete records through poorly documented:
• Admission / discharge arrangements
• Risk assessments
• Essential monitoring reports
• Engagement with family members
• Engagement with other professionals
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. Audit
3. Information Recorded
4. Competence to Record
5. Professional Supervision
6. Patient Awareness/Inclusion
7. Issues Related to Time
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
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.
Strand 1
•
Piloting a new
Regional Nursing
Assessment & Plan of
Care document
•
Standards for nursing
and midwifery record
keeping practice (NI)
Strand 2
Practice Improvement
Programme
www.nipec.hscni.net/recordkeeping/
Abbreviations
Column Column Column Column Column
1
2
3
4
5
Row 1
↑
↓
P
→
Row 2
Pt
MO
Rx
IVF
Row 3
Q
ABX
P
SB
LTOT
Row 4
A/W
SOBOE
D/F
#
IX
@
1.“Pt complaining of pain, paracetamol given at
3pm with good effect, pain↓”
2.“Pt pyrexic, ? UTI, Paractemol 1gram given-if
temp does not reduce –Q source”
3.“Pt admitted c/o chest tightness and soboe. Pt
sb dr p FWT and trop if raised ref echo
a/w angio.
4.patient has abdominal cramp → paracetamol ∏. Pt
reviewed by MO – issues 1/(1.48)↓ ca, ↓mg, ↑ Phos (1.36.
Plan: continue Iron supplement. 2/ (L) knee effusion-↓
mobility. 3/ CRP ↑. Patient for ABX if temp pain,
FBP , A/W results.
5.Mary states she is now painfree. OTT unaided several times
today. No SOBOE noted. P continue to await ct scan ?D
tomorrow.
6.Pt atw @3pm c/o abdo pain. SB Dr on wr P= NPO, xray,
fbp u and e aw results. IVF running 1L/24 hrs. Mgso4
prescribed 10mg IV. Husband in attendance.
7.Fred re atw this pm with exac copd. LTOT @home. Sats on
admission @6Lo2 8%. IV RACF P IVABs, Sp OS and
ABG.
What are the Issues for Staff
• Competing priorities and pressures at ward level.
• Duplication of Records or information required.
• Lack of Guidance-Current Trust Policy.
For the
Person
Outcomes
Safer person centred care
For the
Nurse
Evidenced through improved
record keeping practice.
For the
Trust
Robust assurance regarding
record keeping standards.
?