Improving Nurse Record KeepingNORTHERN IRELAND
NURSING/MIDWIFERY AGENCY EVENTFRIDAY 25TH JANUARY 2013
The quality of a registrants record keeping is a reflection of the standard of their professional practice. 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)
NMC Fitness to Practice Hearings
Failure to Maintain Adequate records06/07: 7.48%
07/08: 10.37% 08/09: 8.53%09/10: 9.57%
10/11: 4%(10/11 No. 6 frequently occurring)
Incomplete records through poorly documented:
• Admission / discharge arrangements• Risk assessments• Essential monitoring reports• Engagement with family members• Engagement with other professionals
Themes Arising from Northern Ireland Public Inquiries 2003 - 2008
Recommendations:
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.
Public Inquiry into the outbreak of Clostridium Difficile in Northern Trust Hospitals. (2011).
January 2009 Purpose Meeting
Literature Review: Factors Influencing Quality of Registrant Record Keeping
The Value and Purpose of Record Keeping
Audit
Information Recorded
Competence to Record
Professional Supervision
Patient Awareness/ Inclusion
Issues Related to Time
….to develop tools for registered nurses that will facilitate
improvement in record keeping.
Piloting the Practice Improvement Programme
Choice of Wards• 5 Medical wards
Improvement Achieved
Learning and Development•Team development•Leadership development•Networking•Shared vision•Championing good practice•Proactive in changing practice•Learning and development in practice
Percentage Increase June 2009 – April 2010
% Increase
Admission & Risk Assessment 11.4
Admission & Risk Assessment (N/A) 25.2
Care Planning 42.4
Care Planning (N/A) 37.4
Discharge Planning 32.9
Mandatory Requirements 41.2 Health Care Support Worker, Student and Error Entries 50
Ave. Total % Inc 34.4
Baseline measurement and continuous audit
Implement learning and development
activities or development of practice activity
Improvement Cycle (Adapted from Deming, 2000)
Re-auditCompare analysis
Sustaining improvement
Four Sections:
Each Section has a Corresponding Section of:
Section 1
Section 2
Section 3
Section 4
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.
Chair: Alan Corry-Finn, WHSCTProject Lead NIPEC: Angela DrurySteering Group members:Royal College of NursingRoyal College of MidwivesQueens University BelfastClinical Education CentreWHSCT, SEHSCT, NHSCT, BHSCT, SHSCTDHSSPS2 Executive Directors of Nursing
Two strands:• Facilitated within HSC Trusts ( 5
Secondment Band 7 Professional Officers – one in each Trust)
• Strand 1: Piloting a new document and development of standards for nursing and midwifery record keeping practice
• Strand 2: Implementing the Record Care tools and resources
• Evaluative methods being used throughout the project
• Final report
• Intended outcome = improved record keeping practice evidenced through audit scores
Paula Boyle SHSCT
Jane PattersonSEHSCT
Sandra HoggWHSCT
Siobhan ShannonNHSCT
Sonya McVeigh BHSCT
Angela DruryNIPEC(Lead Officer)
Progress so Far
• Trusts have implemented the new document• Workshop undertaken in November to evaluate
and refine document• Stream lining of risk assessment tools• Standards production and consultation• Practice Improvement Programme being
implemented• Monthly audit cycles recording significant
improvement• Future continuation proposal under discussion• Contact with RCN
Progress so Far
• Contact with Nursing banks and Agencies• Contact with Universities and representatives
for pre-registration nursing programmes.
So What? – Implications for Agency Staff
• Raise awareness – feedback from HSC Trusts
• Standards document
• Potential for future work with agency staff in this area of practice
• Access to tools and resources via website
Top Related