Challenge Michelle Burke, Professional Officer In attempting to - - PowerPoint PPT Presentation

Recording Care – The Nursing Challenge

Michelle Burke, Professional Officer

‘In attempting to arrive at the truth, I

have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison....’ Florence Nightingale 1863

‘Mrs Harry denies a series of charges dating between 1998 and 2006 and related to alleged failures to ensure adequate nursing staffing levels and appropriate standards of record keeping, hygiene and cleanliness, administration of medication, provision of nutrition and fluids and patient dignity.’

What it’s not.....

What it is.....

• Regional person-centred

nursing assessment and plan

• f care document What √
• Standards for Nursing and

Midwifery Record Keeping Practice How √

• Improved record keeping

practice - 30% increase in audit scores Re Results! lts!

Outcomes

How?

Time and Effort Work-based learning Partnership with Practice Improvement demonstrated in Practice Encouraging and engaging with teams

Outcomes

System of accountability to regionally monitor standards of nurse record keeping practice

• Endoscopy Day Case Record
• Children’s in-patient record
• Learning Disability record
• Emergency Department record
• Health Care Support Worker Framework
• Review of Record Keeping Guidance and Standards
• Regional Abbreviations policy (sep project)
• Documentation audit & Review of NOAT
• Review of web resources

Ongoing Work

• Children’s improvement
• Learning Disabilities improvement
• Emergency Department improvement
• Care planning
• Links to revalidation
• Adult in-patient record review

Endoscopy Day Case Record

Children’s in-patient record

Learning Disability record

Emergency Department record

Health Care Support Worker Framework

http://www.nipec.hscni.net/previousworkandprojects/highstandardsnm/recordkeep ing-for-hcsw/recordkeeping-hcsw-docs/

http://www.nipec.hscni.net/previousworkandprojects/highstandardsnm/recordkeeping-for-hcsw/

Review of Record Keeping Guidance and Standards

http://www.nipec.hscni.net/resource-section/improve-record-keeping/stds-of-recording-care/reg-agreed-stds/ ng Guidance and Standards

Regional Abbreviations policy

http://www.nipec.hscni.net/previousworkandprojects/highstandardsnm/statement-on-abbreviations/ http://www.nipec.hscni.net/wpfb-file/principle-standards-for-the-use-of-abbreviations-aug16-pdf/

Documentation audit & Review of NOAT

http://www.nipec.hscni.net/resource-section/improve-record-keeping/impro-your-record-kep-pract/meas-ident/

Audit Tool: Short NOAT

All entries to the record are legible, accurate and attributable demonstrated through: 1 Legible handwriting 2 Accurate, factual records that do not include jargon, meaningless phrases or text style language 3 Dated 4 Timed ( 24 hour clock) 5 Signed at each entry 6 Name and job title printed alongside the first entry to the record 7 Unique Health and Social Care (HSC) number is on each separate element

Audit Tool: NOAT

All entries to the record: *Person refers to child/young person/adult Y N 1 are dated 2 are timed (24 hour clock) 3 are signed in full (no initials) 4 are designation at 1st entry 5 are written in black ink 6 has a unique patient Health and Social Care number is on each single page 7 has legible hand writing 8 are recorded in real time/chronological order 9 made by a nursing student/s are countersigned by a registered nurse 10 made by a health care support worker comply with local countersignature policies. 11 are free from jargon, meaningless phrases or text-style language 12 are free from speculative or opinion based statements 13 That have errors, are dated 14 That have errors, are timed (24 hour clock) 15 That have errors, signed in full (no initials) 16 That have errors, are attributable 17 That have errors, are crossed out with a single line

Short NOAT

Audit Tool: NOAT

*person also refers to parent/person with parental responsibility Y N 1 The plan of care records evidence of that all needs of the person have been identified in the initial assessment 2 The plan of care records that the person was involved in discussion regarding his/her plan of care (If person lacks understanding click yes) 3 The plan of care records the preference of the person (if person unresponsive click yes) 4 The plan of care records all the relevant needs identified by the completed risk assessments 5 The records demonstrate that the religious/cultural needs of the person have been accommodated 6 The records demonstrate that the frequency of evaluation of planned care/treatment/support has been recorded 7 The records demonstrate that the plan has been evaluated 8 The records demonstrate that the plan identifies outcomes for all planned care/ treatment/support 9 The records demonstrate the persons progress towards all outcomes 10 The records demonstrate were outcomes are not met the plan is updated to implement new care/ treatment/support 11 The record is updated when an outcome has been achieved 12 The record is updated when a new need is identified 13 Incidents/accidents are recorded 14 Following an incident/accident, the plan of care is updated to include all relevant interventions/actions 15 Records demonstrate that ongoing care /treatment/support have been discussed with the person (If person lacks understanding click yes) 16 The records demonstrate the ongoing planned care/ treatment/support included the preferences of the person ( if person unresponsive click yes) 17 The records demonstrate ongoing communication with the multi professional team ,in relation to the person’s care 18 The records demonstrate ongoing communication with relatives/carers, in relation to the person’s care, with their permission 19 The records demonstrate that there is a record of discussions with the person in relation to

• btaining consent for care/treatment/support

Quarterly Quality Focus

Review of web resources

http://www.nipec.hscni.net/ http://www.nipec.hscni.net/resource-section/ http://www.nipec.hscni.net/resource- section/improve-record-keeping/

Future Encompass Programme

• Deliver whole system approach to digitization
• Electronic health care records a single record

across all care settings, formatted to suit each professional. Encompass events

Encompass is coming

Encompass is coming – it’s the future digital platform for health and wellbeing for Northern Ireland – come along and give your expert advice. We want to hear from all roles and grades, particularly frontline staff. We are gathering together people with expertise and experience from throughout the HSC, including those representing patients and the public and voluntary organisations, to help guide the Encompass programme. We are currently seeking input in preparation for making the important decision about choosing the main supplier and solution and are seeking expressions of interest for participation in one of three regional workshops to develop a number of stories (scenarios):

Wednesday 22nd November, 9.30am – 1.00pm Craigavon Civic Centre, 66 Lakeview Rd, Craigavon BT64 1AL Thursday 7th December, 9.30am – 1.00pm Waterfoot Hotel, 14 Clooney Rd, Londonderry BT47 6TB Monday 11th December, 9.30am – 1.00pm Mossley Mill, Carnmoney Road North, Newtownabbey BT36 5QA

Ella.Jameson@hscni.net with nominations by 27th October 2017

Where to find out more about Recording Care Project

NIPEC

• Website

http://www.nipec.hscni.net/

• Microsite

http://www.nipec.hscni.net/resource- section/improve-record-keeping/