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Paediatric Nursing Documentation Re-audit June 2007

Paediatric Nursing Documentation Re-audit June 2007. Tracy McLean – Matron Vivian Kernick – Paediatric Staff Nurse Facilitated by: The Clinical Audit and Effectiveness Department. Paediatric Nursing Documentation Re-audit – June 2007. Objective:

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Paediatric Nursing Documentation Re-audit June 2007

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  1. Paediatric Nursing Documentation Re-audit June 2007 Tracy McLean – Matron Vivian Kernick – Paediatric Staff Nurse Facilitated by: The Clinical Audit and Effectiveness Department

  2. Paediatric Nursing Documentation Re-audit – June 2007 Objective: • To ensure nursing documentation is in line with NSF standards Rationale: • Ensure nursing documentation is completed appropriately • Improve current documentation • Ensure documentation meets NSF standards

  3. Paediatric Nursing Documentation2006 (n=25) & 2007 (n=30) Criterion Number 1: Observation Charts will: A. Be legible B. Be written in black ink C. Relate to prescribed care Exception: None

  4. Paediatric Nursing Documentation2006 (n=25) & 2007 (n=30) Criterion Number 2: All pieces of documentation can be identified as belonging to the patient Exception: None

  5. Paediatric Nursing Documentation2006 (n=25) & 2007 (n=30) Criterion Number 3: The records will demonstrate logical, chronological detail of events Exception: None

  6. Paediatric Nursing Documentation2006 (n=25) & 2007 (n=30) Criterion Number 4: Resident parent check-list will be completed on care plan Exception: Parent/Carer is already familiar with the ward

  7. Paediatric Nursing Documentation2006 (n=25) & 2007 (n=30) Criterion Number 5: Contact with parent/carer will be documented Exception: None

  8. Paediatric Nursing Documentation2006 (n=25) & 2007 (n=30) Criterion Number 6: Nursing discharge summary will be fully completed Exception: None

  9. Paediatric Nursing Documentation2006 (n=25) & 2007 (n=30) Criterion Number 7: Nursing discharge copy will be signed Exception: None

  10. Paediatric Nursing Documentation2006 (n=25) & 2007 (n=30) Criterion Number 8: Only one copy of nursing discharge summary will be present in patients medical records Exception: None

  11. Paediatric Nursing Documentation2006 (n=25) & 2007 (n=30) Criterion Number 9: Nursing discharge summary is faxed to School Health / Health Visitor Exception: Patient non resident in area

  12. Paediatric Nursing Documentation2006 (n=25) & 2007 (n=30) Criterion Number 10: Patients will have: A) Height recorded B) Weight recorded Exception: None

  13. Paediatric Nursing Documentation2006 (n=25) & 2007 (n=30) Criterion Number 11: Patient will have an Early Warning Score recorded with each set of observations Exception: Glasgow Coma Scale Recorded However; often only 1 set not completed

  14. Paediatric Nursing Documentation2006 (n=25) & 2007 (n=30) Criterion Number 12: Invasive procedures / techniques will be recorded Exception: No invasive procedure/techniques performed. Invasive procedure/techniques performed by other department

  15. Paediatric Nursing Documentation2006 (n=25) & 2007 (n=30) Criterion Number 13: Accountability will be signed by a trained nurse Exception: None

  16. Paediatric Nursing Documentation Re-audit – June 2007n=30 Recommendations / Action Plan • Update all staff by displaying audit results • Encourage all staff including house keepers to complete documentation • Included documentation teaching in induction programmes for trained staff and students • Re-audit in 1 year

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