Measure and Identify
The process to improve record keeping practice begins with measuring.
The audit tool – NOAT should be used. The purpose of this tool is to measure the standard of record keeping practice.
The results provide evidence of good practice and areas that require improvement.
The questions asked in NOAT are known as ‘indicators’ and these will help assess the standard of record keeping practice. They have been regionally agreed and should not be altered.
Each HSC Trust should have a method by which it can can collate audit results in order to report them.
The NOAT tool has the following four sections:
Section A Section B Section C Section D Initial assessment and risk assessment Ongoing assessment/ plan of care/ evaluation Discharge, transfer and final placement planning Content and presentation
Click on the links below to download the 4 NOAT audits currently available for use:
DOCUMENTATION AUDIT – ADULT IN-PATIENT (Printable)
DOCUMENTATION AUDIT – CHILDRENS IN-PATIENT (Printable)
DOCUMENTATION AUDIT – EMERGENCY DEPARTMENT (Printable)
Number of auditors
- Two trained independent auditors are considered best practice. Must be members of the nursing team.
Who and How
- individual registrants
- sisters/charges nurses
- PACE facilitators
- Transforming Nursing and Midwifery Data (TMND) officers
When carrying out the NOAT audit, you can complete one section at a time or take the full approach, all sections at once:
There is step by step guidance available on how to use the tool by clicking here
Auditing Nursing Records
The number of records to audit depends on the approach taken;
Full audit with all four sections of the audit or Section approach taking one section at a time:
Approach Week No’ Week No’ Full audit – all sections Baseline 1 and 32 10 4,8,12,16,20,24 5 By sections Baseline 1 5 4,8,12,16,20,24,32 5
SHORT NOAT – 5 Records as all sections require completion , section approach is not optional.
Which Care Setting
The indicators contained within Short NOAT can be applicable to all care settings.
The larger tool NOAT has the option to have profiles for different care setting.
A profile is made up of questions that are relevant to the care setting which you practise, there are 16 care settings.
View the Care Setting Profiles below or in pdf format here:
Adult Acute Learning Disability In-Patient Emergency Department Children Acute Mental Health In-Patient Day Case Maternity Specialist Nurse Practitioner Adult Community Learning Disability Community Health Visiting Children Community Mental Health Community School Nursing Independent/Voluntary Prison
Contact NIPEC regarding creating a care setting profile for your area of practice.