Recording Care: Evidencing Safe and Effective Care

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

2. The Nursing and Midwifery Councilstates:‘Good record keeping helps to protect the welfare of patients and clients’ Good record keeping is a mark of a skilled and safe practitioner, while careless or incomplete record keeping often highlights wider problems with an individual's practice.’ (NMC 2007) Jane Doe

3. Background Themes Arising from Northern Ireland Public Inquiries, Official Reports and Critical Incident Reviews 2003 - 2008 Incomplete records through poorly documented: • Admission / discharge arrangements • Risk assessments • Essential monitoring reports • Engagement with family members • Engagement with other professionals

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. 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

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 (NI)

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

10. Abbreviations P

11. 1.“Pt complaining of pain, paracetamol given at 3pm with good effect, pain↓” 2.“Pt pyrexic, ? UTI, Paractemol 1gram given-if temp does not reduce –Q source” 3.“Pt admitted c/o chest tightness and soboe. Pt sb dr p FWT and trop if raised ref echo a/w angio.

12. 4.patient has abdominal cramp → paracetamol ∏. Pt reviewed by MO – issues 1/(1.48)↓ ca, ↓mg, ↑ Phos (1.36. Plan: continue Iron supplement. 2/ (L) knee effusion-↓ mobility. 3/ CRP ↑. Patient for ABX if temp pain, FBP , A/W results. 5.Mary states she is now painfree. OTT unaided several times today. No SOBOE noted. P continue to await ct scan ?D tomorrow.

13. 6.Pt atw @3pm c/o abdo pain. SB Dr on wr P= NPO, xray, fbp u and e aw results. IVF running 1L/24 hrs. Mgso4 prescribed 10mg IV. Husband in attendance. 7.Fred re atw this pm with exaccopd. LTOT @home. Sats on admission @6Lo2 8%. IV RACF P IVABs, Sp OS and ABG.

14. What are the Issues for Staff • Competing priorities and pressures at ward level. • Duplication of Records or information required. • Lack of Guidance-Current Trust Policy.

15. 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.

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