Recording Care: Evidencing Safe and Effective Care

1. Recording Care: Evidencing Safe and Effective Care Professional Officers Sonya McVeigh & Siobhan Shannon BHSCT & NHSCT

2. 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

3. 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

4. Regional Record Keeping Initiative (2009/10)(RRKI) • http://www.nipec.hscni.net/pw_recordkeeping.htm • Literature Review: • Value and Purpose of Record Keeping • Audit • Information Recorded • Competence to Record • Professional Supervision • Patient Awareness/Inclusion • Issues Related to Time

5. 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

6. 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.

7. Strand 1 • Piloting a new Regional Nursing Assessment & Plan of Care document • Standards for nursing and midwifery record keeping practice

8. Strand 2 Practice Improvement Programme www.nipec.hscni.net/recordkeeping/

11. For the Person Safer person centred care Outcomes For the Nurse • Evidenced through improved record keeping practice. For the Trust • Robust assurance regarding record keeping standards.

13. What’s The Future? • Phase 2 • Mental health, Learning disabilities and Paediatrics • Potential for movement into the community • Improvement methodologies implemented • NOAT amended

14. 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

15. Thank you!