Assessment & Records
Person-centred Assessment of Nursing and Midwifery Need and Recording Care
Where high levels of service demand are likely, it is especially important that information being captured around assessment of nursing or midwifery need linked to a plan of care is appropriate, current and accessible.
Person-centred nursing and midwifery assessment comprises different sets of criteria for each care setting. Each person that enters any clinical setting will have individual health and wellbeing needs based on previous and current conditions. For example the nursing assessment criteria and risk assessments used in adult hospital based environments are different to those used in children’s, learning disabilities, district nursing and mental health settings. The principles in this microsite, however, can be adapted to the type of assessment completed. Links will also be made available to other resources, to assist in the assessment of nursing and midwifery care needs.
All registered nurses and midwives will have assessment skills with varying degrees of applicability to the setting they find themselves in, under redeployment and emergency COVID-19 arrangements. Nurses and midwives may also find themselves in situations where it is not possible to carry out a full assessment for a number of patients in their care at a particular point of time when they enter the clinical setting due to a variety of reasons.
In these circumstances the principles below apply:
For additional information specific to particular care settings e.g. Private Nursing Homes, please see below.
Ensure critical areas of information: alerts, allergies, do not resuscitate orders, IPC and moving and handling risk assessments, and psychological assessments are always assessed and recorded.
ASSESSMENT OF NURSING OR MIDWIFERY NEED
Where it is not possible to assess all of the criteria, professional judgement should then be used to prioritise the most relevant assessment criteria and other risk assessments to the immediate presenting need of the individual being cared for.
Where it has not been possible to assess all of the needs of the person, record those areas which require further review and record for the next shift. In many of the records for the differing fields of practice there is a section to complete a record of what remains incomplete for example, the regional adult record at page 15. It is good practice to include a short reason as to why it was not possible to record all assessed needs.
All registered nurses and midwives are responsible for assessment of need within their scope of practice, therefore subsequent teams coming on shift should review the assessment of need adding to it where they can, again tracking those areas that were unable to be covered for the next complement of staff coming on shift.
There are also some aspects of nursing and midwifery assessment and planning of care that may require further thought and consideration based on the within any given team on a shift by shift basis:
COMPETENCE TO ASSESS
Identify who, in the available team of people each shift, is familiar with the range of assessment needs that people usually present with in this clinical setting and are therefore able to competently assess needs.
For example: In critical care settings presenting needs will be complex and require more technical plans of nursing interventions and care to meet these needs appropriately.
COMPETENCE TO PLAN NURSING AND MIDWIFERY CARE AND TREATMENT
Where a small number of appropriately skilled nurses or midwives are available to assess needs effectively, thought should be given as to how to manage daily review of care needs. Based on the prescribed plans of care for individual patients, small teams of individuals may have tasks and duties delegated to them to ensure the full complement of care needs are carried out for all people in the care environment.
The PACE framework for planning nursing and midwifery care provides a method for assessment of need on a shift-by-shift basis and effectively evidencing a person-centred plan of care. Information on the framework can be found here.
COMPETENCE TO EVALUATE CARE AND TREATMENT
It will be helpful to identify who, within the team for that day, is appropriately skilled to record evaluations of care and treatment planned in the nursing or midwifery records. This may not be all members of the team – please note: where another member of the team has carried out a delegated task or duty and is reporting back this should be identified in the record of care e.g.
080420 12:00hrs SNA Jennie Smyth reported that John’s wound dressing was intact and had no exudate strikethrough. S Wilson. RN.
This factor will also be relevant if members of the team are making entries to a digital system on behalf of others in the team who do not have an individual login or access to a temporary login, due to the volume being provided during COVID-19.
NOTE! Remember to check your own organisational policies on using temporary logins.
The principles on this site can be adapted to the type of care setting where the assessment is being completed. As previously mentioned in the principles for recording care in this microsite, person-centred nursing and midwifery assessment comprises different sets of criteria for each care setting. In private nursing home settings, the assessment of individual health and wellbeing needs should be based on previous and current conditions, against a set of agreed evidence-informed criteria for the home setting.
This may include individual risk assessments that the nursing home has approved for use, where staff have been developed to use them effectively.
Other resources which may assist include: