1. Recording Care – The Challenge
Toward 2020: Celebrating Nursing and Midwifery Leadership
3rd Commonwealth Nurses and Midwives Conference
13th March 2016

2. ‘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

3. ‘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.’

4. Nursing records underpin practice….so….

5. Evidence Base
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

6. Recording [nursing and midwifery] Care......
What’s the point?

7. What it’s not.....

8. What it is.....
Practice!

9. Recording Care
2009
2010
2011
2012/13
2014
2015
2016

10. Recording Care
Aim:
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.
Data standards for nursing assessment and plan of care document
Improvement methods

11. Recording
Care

12. Outcomes
Standards for Nursing and Midwifery Record Keeping Practice How √
Regional person-centred nursing assessment and plan of care document What √
Improved record keeping practice - 30% increase in audit scores Results!

13. Changing Practice Work-based Activities Time and Effort
Focus on Person-centred Practice
Work-based Activities
Learning Integrated into Practice
Encouraging Teams

14. Nothing about me without me.....
People at the Centre
Nothing about me without me.....

15. Ongoing Work
System of accountability to regionally monitor standards of nurse record keeping practice
Key Performance Indicator development
Data standards – endoscopy, children’s, learning disabilities
Health Care Support Worker Practice
Care planning
Links to revalidation

16. Learning

17. Learning Regional Sign-up
Leadership (Executive Nurse to Champion – CNO commission)
Facilitation
Listen to the frontline
Clear goals
Accountability
Tenacity and Enthusiasm
Value and mark achievement
(Never give up)

18. & ‘s
“It ain’t what you do it’s the way that you do it, and that’s what get results…” X X

19. One small system change......