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

2. Leading Care, Leading Teams – Shaping the Future Ward Sister/Charge Nurse and Team Leader Conference, 17 th April 2013 Background Themes Arising from Northern Ireland Public Inquiries 2003 - 2008 Incomplete records through poorly documented: Admission / discharge arrangements Risk assessments Essential monitoring reports Engagement with family members Engagement with other professionals

3. Leading Care, Leading Teams – Shaping the Future Ward Sister/Charge Nurse and Team Leader Conference, 17 th April 2013 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

4. Regional Record Keeping Initiative (2009/10)(RRKI) http://www.nipec.hscni.net/pw_recordkeeping.htm Literature Review: 1.Value and Purpose of Record Keeping 2.Audit 3.Information Recorded 4.Competence to Record 5.Professional Supervision 6.Patient Awareness/Inclusion 7.Issues Related to Time

5. Good record keeping helps to protect the welfare of patients and clients’ (NMC, 2002) The Nursing and Midwifery Council states: ‘Good record keeping helps to protect the welfare of patients and clients’ (NMC, 2002) 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) Jane Doe

6. Leading Care, Leading Teams – Shaping the Future Ward Sister/Charge Nurse and Team Leader Conference, 17 th April 2013 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. Leading Care, Leading Teams – Shaping the Future Ward Sister/Charge Nurse and Team Leader Conference, 17 th April 2013 Strand 1 Piloting a new Regional Nursing Assessment & Plan of Care document Standards for nursing and midwifery record keeping practice

8. Leading Care, Leading Teams – Shaping the Future Ward Sister/Charge Nurse and Team Leader Conference, 17 th April 2013 Strand 2 Practice Improvement Programme www.nipec.hscni.net/recordkeeping/

9. Leading Care, Leading Teams – Shaping the Future Ward Sister/Charge Nurse and Team Leader Conference, 17 th April 2013

10. Leading Care, Leading Teams – Shaping the Future Ward Sister/Charge Nurse and Team Leader Conference, 17 th April 2013

11. Leading Care, Leading Teams – Shaping the Future Ward Sister/Charge Nurse and Team Leader Conference, 17 th April 2013 Safer person centred care Evidenced through improved record keeping practice. Robust assurance regarding record keeping standards. For the Person For the Nurse For the Trust Outcomes

12. Leading Care, Leading Teams – Shaping the Future Ward Sister/Charge Nurse and Team Leader Conference, 17 th April 2013

13. Leading Care, Leading Teams – Shaping the Future Ward Sister/Charge Nurse and Team Leader Conference, 17 th April 2013 What’s The Future? Phase 2 Mental health, Learning disabilities and Paediatrics Potential for movement into the community Improvement methodologies implemented NOAT amended

14. Leading Care, Leading Teams – Shaping the Future Ward Sister/Charge Nurse and Team Leader Conference, 17 th April 2013 What’s The Future? E-record developed for acute in-patient services Under 24 hour stay document Care-planning explored – development of nursing informatics system Launch of Standards document Abbreviations policy development

15. Leading Care, Leading Teams – Shaping the Future Ward Sister/Charge Nurse and Team Leader Conference, 17 th April 2013