Improving Nurse Record Keeping

NORTHERN IRELAND NURSING/MIDWIFERY AGENCY EVENT FRIDAY 25

TH

JANUARY 2013

The quality of a registrants record keeping is a reflection of the standard of their professional practice. 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) NMC Fitness to Practice Hearings Failure to Maintain Adequate records 06/07: 7.48% 07/08: 10.37% 08/09: 8.53% 09/10: 9.57% 10/11: 4% (10/11 No. 6 frequently occurring)

Themes Arising from Northern Ireland Public Inquiries 2003 - 2008 Incomplete records through poorly documented:

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Admission / discharge arrangements

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Risk assessments

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Essential monitoring reports

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Engagement with family members

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Engagement with other professionals

Public Inquiry into the outbreak of Clostridium Difficile in Northern Trust Hospitals. (2011).

Recommendations: 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.

January 2009 Purpose Meeting

Literature Review: Factors Influencing Quality of Registrant Record Keeping

The Value and Purpose of Record Keeping Audit Information Recorded Competence to Record Professional Supervision Patient Awareness/ Inclusion Issues Related to Time

….to develop tools for registered nurses that will facilitate improvement in record keeping.

Piloting the Practice Improvement Programme Choice of Wards • 5 Medical wards Improvement Achieved Learning and Development •Team development •Leadership development •Networking •Shared vision •Championing good practice •Proactive in changing practice •Learning and development in practice

Percentage Increase June 2009 – April 2010

Admission & Risk Assessment Admission & Risk Assessment (N/A) Care Planning Care Planning (N/A) Discharge Planning Mandatory Requirements Health Care Support Worker, Student and Error Entries Ave. Total % Inc % Increase 11.4 25.2 42.4 37.4 32.9 41.2 50 34.4

Improvement Cycle (Adapted from Deming, 2000)

Sustaining improvement Re-audit Compare analysis Baseline measurement and continuous audit Implement learning and development activities or development of practice activity

Four Sections:

Each Section has a Corresponding Section of:

Section 1

Section 2

Section 3

Section 4

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.

Chair: Alan Corry-Finn, WHSCT Project Lead NIPEC: Angela Drury Steering Group members: Royal College of Nursing Royal College of Midwives Queens University Belfast Clinical Education Centre WHSCT, SEHSCT, NHSCT, BHSCT, SHSCT DHSSPS 2 Executive Directors of Nursing

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Two strands: Facilitated within HSC Trusts ( 5 Secondment Band 7 Professional Officers – one in each Trust) Strand 1: Piloting a new document and development of standards for nursing and midwifery record keeping practice Strand 2: Implementing the Record Care tools and resources

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Evaluative methods being used throughout the project Final report Intended outcome = improved record keeping practice evidenced through audit scores

Jane Patterson SEHSCT Sandra Hogg WHSCT Siobhan Shannon NHSCT Paula Boyle SHSCT Angela Drury NIPEC (Lead Officer) Sonya McVeigh BHSCT

Progress so Far

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Trusts have implemented the new document Workshop undertaken in November to evaluate and refine document Stream lining of risk assessment tools Standards production and consultation Practice Improvement Programme being implemented Monthly audit cycles recording significant improvement Future continuation proposal under discussion Contact with RCN

Progress so Far

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Contact with Nursing banks and Agencies Contact with Universities and representatives for pre-registration nursing programmes.

So What? – Implications for Agency Staff

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Raise awareness – feedback from HSC Trusts

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Standards document

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Potential for future work with agency staff in this area of practice

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Access to tools and resources via website