0. PAEDIATRIC RISK ASSESSMENT & NURSING CARE ASSESSMENT CHARTS
EDUCATION
Office of Kids Families December 2015

1. Background
ACT/NSW Paediatric & Children’s Healthcare Network Clinical Nurse Consultants group identified the need for standard Paediatric Risk / Nursing Assessment charts
Aim to reduced unwarranted clinical variation in the care for children across NSW no matter where they present
NSW Kids and Families facilitated a State working party to develop the charts, with representation from tertiary and non-tertiary facilities including rural and remote sites across NSW
This group developed charts aimed for state-wide consistency for children and adolescents admitted to acute paediatric in-patient areas. Paediatric sub-specialty areas may add/utilise their own forms

2. Consultation
Office of Kids and Families (Paediatrics, Maternity, Child Protection, Youth Health)
Children’s Healthcare Network
Sydney Children’s Hospitals Network
Clinical Excellence Commission
State Forms Management Committee
E-Health (to harmonise with development of EMR2)
Nursing & Midwifery Office
Statewide consultation to clinicians and managers via LHD CEs and DoNMs
Trial sites: Bega, Goulburn, RNSH, Manning, Broken Hill, SCHN & JHCH

3. Why do we need standard forms?
The Children’s Healthcare Network State Paediatric Clinical Nurse Consultants group identified a need for standardised paediatric risk assessment charts for acute paediatric in-patient units:
To meet the National Safety and Quality Health Service (NSQHS) Standards
To meet the clinical needs common to acute paediatric wards
To avoid duplication and reduce number of assessment charts
To include mandated tools (e.g. falls, pressure injury, nutrition)

4. The charts
Paediatric Risk Assessment Form (incorporating either the modified Glamorgan or Braden Q pressure injury scale)
Paediatric Nursing Assessment & Care Plan
(Paediatric Nursing Care Plan - extended stay form available for longer admissions)

5. Completing the charts
To be completed by the admitting nurse on patients admitted to an acute paediatric in-patient area.
All sections of the charts are mandatory.
Nursing staff need to use clinical judgement to assess if the situation is appropriate to complete the assessment forms immediately upon admission.
If charts cannot be completed during the admission process then omissions and reasons why need to be recorded in the healthcare record.

6. Why two charts?
The charts were not developed as a single booklet as some information can be at the bedside and some cannot.
Bedside: Paediatric Nursing Assessment & Care Plan can be used as a working document in the bedside notes during admission and filed in healthcare record following discharge (refer to current ward practice)
Healthcare Record: The Paediatric Risk Assessment form is to be kept in the patient’s’ healthcare record and NOT at the bedside as it contains child protection screening information.

7. EMR and the charts
The information in the paper copies and the information required in EMR2 are the same.
The formats for each vary but not the information
You need to complete EMR or paper copies – as per local facilities procedure

8. Paediatric Risk assessment chart

9. Paediatric Risk Assessment Chart (Page 1)

10. Page 1 - Paediatric Risk Assessment
Incorporating several mandatory risk assessment tools:
modified Glamorgan or Braden Q pressure injury
Humpty Dumpty falls
Nutritional
Child safety and welfare
Additional risk assessment information relates to:
Social history
Risk assessment
Behaviour, emotion, mental health
Infection control

11. Page 2 - Incorporating Falls Assessment

12. Page 2 - Paediatric Falls Assessment
Initial assessment - Falls risk - adapted from the Miami Humpty Dumpty falls risk assessment
To be used in conjunction with the CEC Paediatric Falls risk program and education. Program information available at:
Initial and subsequent scores and level of risk to be recorded in the Care Plan
‘Action column’ to guide staff how to action an identified falls risk. Document any actions taken in the health care record

13. Page 3 – Glamorgan Pressure Injury Tool

14. Page 3 – Braden Q Pressure Injury Tool

15. Page 3 - Paediatric Pressure Injury
Initial Assessment - Pressure Injury Risk Assessment using either the modified Glamorgan or Braden Q scale
Visualise skin and document integrity on care plan
Initial and subsequent scores and level of risk to be recorded in the Care Plan. Document any changes in health care record
‘Action required’ column to guide staff in management

16. Page 4 – Child Protection

17. Page 4 - Child Protection
Child Safety, Welfare and Wellbeing Risk Assessment - taken from the Mandatory Reporter Guide
For staff use only - Health care professional observation and assessment form
Parents/carers are NOT to be asked these questions
This is an initial assessment on admission. Staff need to re-assess if any concerns arise during the admission
‘Action required’ column to guide staff - area for staff to write concerns

18. Paediatric Nursing assessment & care plan chart

19. Page 1 – Paediatric Nursing Assessment Can be kept at the bedside or as per usual practice for unit To be completed on admission to the ward - Admission details - Orientation to the ward - Nursing Assessment

20. Brochures Your Health Rights and Responsibilities –
A Guide for Patients, Carers & Families
What you need to know about Information Privacy
Youth Friendly Confidentiality Resources
We keep it zipped – we provide a confidential service for young people

21. Pages 2 & 3 - Paediatric Nursing Care plan To be completed initially and updated when care changes (not necessary to change each shift unless required) For Falls Risk and Pressure Area Care sections of the care plan document score and risk actions required Extended stay care plans available as a single additional page

22. Nursing Care Plan
Care Plans are to be revised and signed for when care changes
Not routinely signed at the end of each shift
May require more than one revision in a shift (e.g. pre and post operatively)
Or may require no revision of care during a shift

23. Page 4 – Discharge Planning
Parent carer authority discharge signature
Parents to sign when patient being discharged

24. Any questions….