Paediatric Nursing Documentation Audit – December 2006

1. Paediatric Nursing Documentation Audit – December 2006 Tracy McLean – Matron Vivian Kernick – Paediatric Staff Nurse Facilitated by: The Clinical Governance & Effectiveness Department

2. Paediatric Nursing Documentation Audit – December 2006 Objective: • To ensure that nursing documentation within ward 10 meets NSF standards Rationale: • To meet NSF for children standards • To develop and improve current practice

3. Paediatric Nursing Documentation Audit – December 2006n = 25 Criterion Number 1: Observation Charts will: • Be legible • Be written in black ink • Relate to prescribed care Exception: None

4. Paediatric Nursing Documentation Audit – December 2006n = 25 Criterion Number 2: All pieces of documentation can be identified as belonging to the patient Exception: None

5. Paediatric Nursing Documentation Audit – December 2006n = 25 Criterion Number 3: The records will demonstrate logical, chronological detail of events Exception: None Criteria met 100%

6. Paediatric Nursing Documentation Audit – December 2006n = 25 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 Documentation Audit – December 2006n = 25 Criterion Number 5: Contact with parent/carer will be documented Exception: None

8. Paediatric Nursing Documentation Audit – December 2006n = 25 Criterion Number 6: Nursing discharge summary will be fully completed Exception: None

9. Paediatric Nursing Documentation Audit – December 2006n = 25 Criterion Number 7: Nursing discharge copy will be signed Exception: None

10. Paediatric Nursing Documentation Audit – December 2006n = 25 Criterion Number 8: Only copy of nursing discharge summary will be present in patients medical records Exception: None

11. Paediatric Nursing Documentation Audit – December 2006n = 25 Criterion Number 9: Nursing discharge summary is faxed to School Health / Health Visitor Exception: Patient non resident in area

12. Paediatric Nursing Documentation Audit – December 2006n = 25 Criterion Number 10: Patients will have: • Height recorded • Weight recorded • Exception: None

13. Paediatric Nursing Documentation Audit – December 2006n = 25 Criterion Number 11: Patient will have an Early Warning Score recorded with each set of observations Exception: None

14. Paediatric Nursing Documentation Audit – December 2006n = 25 Criterion Number 12: Invasive procedures/ techniques will be recorded Exception: No invasive procedures / techniques performed or performed by other department

15. Paediatric Nursing Documentation Audit – December 2006n = 25 Criterion Number 13: Accountability will be signed by a trained nurse Exception: None

16. Paediatric Nursing Documentation Audit – December 2006 Recommendations • Resident care plan to be completed (Housekeeper and pre-clerking staff) • Nursing discharge to be re-launched and re-audited – April 2007 • All staff to be educated in importance of height recording • Paediatric Early Warning Score – All nursing staff have been re-educated in importance and frequency of using it • Invasive procedures – ward Sisters to monitor completion of this documentation • Accountability – all staff have been re-educated in the importance of signing accountability • Re-audit July 2007