1. Guidance on Improving Record Keeping Practices Brenda Devine Senior Professional Officer, NIPEC

2. Structure Professional Accountability Consequences of poor record keeping practice NIPEC Guide Engagement Process Examples from the Guide Next Steps

3. Professional Accountability NMC 2009 states that…… “ Good record keeping is an integral part of nursing and midwifery practice, and is essential to the provision of safe and effective care”

4. Good Record Keeping helps to protect the welfare of the patient/clients by ensuring High standards of clinical care Continuity of care Better communication and dissemination of information between members of the interprofessional health care team An accurate account of treatment and care planning and delivery The ability to identify risks and detect problems, such as changes in the patient / clients condition at an early stage

5. 2008/09 Failure to maintain Adequate records 8.52% 2007/08 Failure to maintain Adequate records 10.37% Professional Conduct & Competence Cases

6. Consequences of Poor Record Keeping Practice

7. Themes from NI Inquiries/Reviews

8. Themes Incomplete records Incomplete care plans Risks not identified or recorded Poorly recorded admission / discharge arrangements Use of Abbreviations

9. Themes cont’d Vital signs not recorded Vital signs – no record of action taken Poorly documented engagement with patient or family members Poorly documented engagement with other professionals

10. Good practice in record keeping is  Fundamental part of practice  Not to be viewed as a distraction from caring for patients  Helpful in the protection of the welfare of patients by ensuring high standards and continuity of care  There to improve communication between members of the healthcare team

11. Cont’d  Viewed as a critical professional skill  Records written appropriately can give practitioners the opportunity to detect problems such as changes in the patients condition  Problematic if records are not eligible and colleagues can not give continuity of care…… then there could be an accusation of liability in negligence

12. Record Keeping is an essential professional skill, if it is not recorded, it has not been done!

13. NIPEC Guide

14. Engagement Process Workshops Regional Record Keeping Initiative

15. Output from Engagement More detail than NMC Guidance Examples of Good Practice Focusing on – Mandatory NMC Requirements – Admission – Care planning – Discharge – Communication with Patients/Relatives

16. NIPEC Guide Content and Style (NMC Principles 1,4,6,7,8,9,33) Patient Identification (NMC Principles 1,17,23,27) Author (NMC Principles 1,2) Point in Time (NMC Principles 1,3,4,6,7,)

17. NIPEC Guide Permanent marker (NMC Principle 14) Complete records (NMC Principles 6, 9, 32, 33) Alterations (NMC Principle 10) Errors (NMC Principle 11) Jargon and Abbreviations (NMC Principle 5)

18. Examples of NIPEC Guide (Mandatory NMC Requirements)

19. Wrong time format - no date NOT GOOD PRACTICE Author & Point in Time 1/01/09 – 16.30hrs Mrs A attended X-Ray today at 14:00hrs for barium enema. Returned to the ward at 16:00hrs with no ill effects and has understood the procedure. Observations recorded on return, within normal limits for Mrs A. The report of the barium enema will be received from x-ray tomorrow. Mrs A states she feels comfortable no pain relief required at present. A. Another Staff/Nurse 21/4/09 – 12.10hrs Maternal observation checked and within normal parameters, neonatal observation checked within normal parameters. Discussed with Anne agreed date for next planned visit. Contact Number given and next visit Friday 24/4/09. B. Another Midwife 4pm At x-ray depart today for barium enema – fine on return AA Mother and baby both well review in 2 days Time & Date using the 24hr format GOOD PRACTICE Name signed in full…, Identifying status and profession GOOD PRACTICE Initials Only NOT GOOD PRACTICE No Date No Time No signature Not enough information NOT GOOD PRACTICE

20. Written in Error 14:00hrs 01/09/09 (written in error J Bloggs S/N) Mrs Another attended X-Ray Dept for (Chest X-Ray) Barium Enema. J.Bloggs. Staff Nurse

21. Next Steps NIPEC Website – Interactive – Webinar