Recording Care – The Nursing Challenge Michelle Burke, Professional Officer
‘ In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison....’ Florence Nightingale 1863
‘Mrs Harry denies a series of charges dating between 1998 and 2006 and related to alleged failures to ensure adequate nursing staffing levels and appropriate standards of record keeping, hygiene and cleanliness, administration of medication, provision of nutrition and fluids and patient dignity.’
What it’s not.....
What it is.....
Outcomes • Regional person-centred nursing assessment and plan of care document What √ • Standards for Nursing and Midwifery Record Keeping Practice How √ • Improved record keeping practice - 30% increase in audit scores Re Results! lts!
How? Work-based Partnership learning Time and Effort with Practice Encouraging Improvement and engaging demonstrated in with teams Practice
Outcomes System of accountability to regionally monitor standards of nurse record keeping practice • Endoscopy Day Case Record • Children’s in -patient record • Learning Disability record • Emergency Department record • Health Care Support Worker Framework • Review of Record Keeping Guidance and Standards • Regional Abbreviations policy (sep project) • Documentation audit & Review of NOAT • Review of web resources
Ongoing Work • Children’s improvement • Learning Disabilities improvement • Emergency Department improvement • Care planning • Links to revalidation • Adult in-patient record review
Endoscopy Day Case Record
Children’s in -patient record
Learning Disability record
Emergency Department record
Health Care Support Worker Framework http://www.nipec.hscni.net/previousworkandprojects/highstandardsnm/recordkeeping-for-hcsw/ http://www.nipec.hscni.net/previousworkandprojects/highstandardsnm/recordkeep ing-for-hcsw/recordkeeping-hcsw-docs /
Review of Record Keeping Guidance and Standards http://www.nipec.hscni.net/resource-section/improve-record-keeping/stds-of-recording-care/reg-agreed-stds/ ng Guidance and Standards
Regional Abbreviations policy http://www.nipec.hscni.net/previousworkandprojects/highstandardsnm/statement-on-abbreviations/ http://www.nipec.hscni.net/wpfb-file/principle-standards-for-the-use-of-abbreviations-aug16-pdf/
Documentation audit & Review of NOAT http://www.nipec.hscni.net/resource-section/improve-record-keeping/impro-your-record-kep-pract/meas-ident/
Audit Tool: Short NOAT All entries to the record are legible, accurate and attributable demonstrated through: 1 Legible handwriting 2 Accurate, factual records that do not include jargon, meaningless phrases or text style language 3 Dated 4 Timed ( 24 hour clock) 5 Signed at each entry 6 Name and job title printed alongside the first entry to the record 7 Unique Health and Social Care (HSC) number is on each separate element
Audit Tool: NOAT All entries to the record: *Person refers to child/young person/adult Y N 1 are dated 2 are timed (24 hour clock) 3 are signed in full (no initials) are designation at 1 st entry 4 5 are written in black ink 6 has a unique patient Health and Social Care number is on each single page 7 has legible hand writing 8 are recorded in real time/chronological order 9 made by a nursing student/s are countersigned by a registered nurse 10 made by a health care support worker comply with local countersignature policies. 11 are free from jargon, meaningless phrases or text-style language 12 are free from speculative or opinion based statements 13 That have errors, are dated 14 That have errors, are timed (24 hour clock) 15 That have errors, signed in full (no initials) 16 That have errors, are attributable 17 That have errors, are crossed out with a single line
Short NOAT
N *person also refers to parent/person with parental responsibility Y The plan of care records evidence of that all needs of the person have been identified in the 1 initial assessment The plan of care records that the person was involved in discussion regarding his/her plan of 2 care (If person lacks understanding click yes) 3 The plan of care records the preference of the person (if person unresponsive click yes) 4 The plan of care records all the relevant needs identified by the completed risk assessments The records demonstrate that the religious/cultural needs of the person have been 5 Audit Tool: accommodated The records demonstrate that the frequency of evaluation of planned care/treatment/support 6 has been recorded 7 The records demonstrate that the plan has been evaluated NOAT The records demonstrate that the plan identifies outcomes for all planned care/ 8 treatment/support 9 The records demonstrate the persons progress towards all outcomes The records demonstrate were outcomes are not met the plan is updated to implement new 10 care/ treatment/support 11 The record is updated when an outcome has been achieved 12 The record is updated when a new need is identified 13 Incidents/accidents are recorded Following an incident/accident , the plan of care is updated to include all relevant 14 interventions/actions Records demonstrate that ongoing care /treatment/support have been discussed with the 15 person ( If person lacks understanding click yes) The records demonstrate the ongoing planned care/ treatment/support included the 16 preferences of the person ( if person unresponsive click yes) The records demonstrate ongoing communication with the multi professional team ,in 17 relation to the person’s care The records demonstrate ongoing communication with relatives/carers , in relation to the 18 person’s care, with their permission The records demonstrate that there is a record of discussions with the person in relation to 19 obtaining consent for care/treatment/support
Quarterly Quality Focus
Review of web resources http://www.nipec.hscni.net/resource- http://www.nipec.hscni.net/resource-section/ section/improve-record-keeping/ http://www.nipec.hscni.net/
Future Encompass Programme • Deliver whole system approach to digitization • Electronic health care records a single record across all care settings, formatted to suit each professional. Encompass events
Encompass is coming Encompass is coming – it’s the future digital platform for health and wellbeing for Northern Ireland – come along and give your expert advice. We want to hear from all roles and grades, particularly frontline staff. We are gathering together people with expertise and experience from throughout the HSC, including those representing patients and the public and voluntary organisations, to help guide the Encompass programme. We are currently seeking input in preparation for making the important decision about choosing the main supplier and solution and are seeking expressions of interest for participation in one of three regional workshops to develop a number of stories (scenarios): Wednesday 22 nd November, 9.30am – 1.00pm Craigavon Civic Centre, 66 Lakeview Rd, Craigavon BT64 1AL Thursday 7 th December, 9.30am – 1.00pm Waterfoot Hotel, 14 Clooney Rd, Londonderry BT47 6TB Monday 11 th December, 9.30am – 1.00pm Mossley Mill, Carnmoney Road North, Newtownabbey BT36 5QA Ella.Jameson@hscni.net with nominations by 27 th October 2017
Where to find out more about Recording Care Project NIPEC • Website http://www.nipec.hscni.net/ • Microsite http://www.nipec.hscni.net/resource- section/improve-record-keeping/
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