Regionally Agreed Standards

The regionally agreed standards were first launched in 2013 and have since been updated, much of the content of the standards document aligns with the NMC Code.  Click here to download the document.

In the regionally agreed standards document the standards are listed as key performance indicators under the four categories below, click on the links to find out more:

• Content

  Page 7

  Entries to records must demonstrate accurate, contemporaneous, factual record keeping practice in relation to the patient/client journey from admission to discharge from the service

  Entries to patient/client records:

  1. Must be accurate, factual and must not include jargon, meaningless phrases or text – style abbreviated language.
  2. Must identify the date and time in 24 hour format. This must be in real time and chronological order, and be as close to the actual time of the event as possible.
  3. Must demonstrate details of all assessments, rick assessments, plans of care and reviews undertaken, and provide clear evidence of the arrangements made throughout a person’s journey from admission to discharge from the service.
  4. Must identify dates and times for the evaluation of the plan of care.
  5. Must demonstrate that review of the plan of care has been carried out.
  6. Must demonstrate evaluation of care and treatment.
  7. Must demonstrate that discharge planning, where appropriate, has commenced at the time a person enters a care setting.
• Person Centred Approaches

  Page 6

  Patient/client records must demonstrate patient/client/carer involvement in the patient/ client journey from admission to discharge from the service

  Entries to patient/client records:

  1. Must demonstrate the involvement of the person for whom care I being provided or where appropriate, and with the person’s consent, the involvement of his/her carer, in the record keeping process.
  2. Must demonstrate that the needs and preferences of the person for whom care is being provided, where appropriate, have been included in the record keeping process.
  3. Must demonstrate that appropriate consent for care/treatment has been sought from the patient/client.
  4. Must be written in a way which can be easily understood by the person for whom care is being provided.
• Governance

  Page 10

  Regular organisational audit must demonstrate compliance with the standards for record keeping practice for nursing and midwifery.

  Entries to patient/client records:

  1. Executive Directors of Nursing must ensure that there is a robust audit programme of records made by nurses and midwives, nursing and midwifery students and other unregistered staff, to assure the standard of record keeping practice and identify any areas where improvements must be made.
  2. The standard of record keeping practice must be an integral part of nursing and midwifery Key Performance Indicators and Patient Safety Improvement programmes within HSC Trust or organisational governance arrangements.
• Presentation

  Page 8

  All entries to patient/client records are legible, accurate and attributable

  Entries to patient/client records:

  1. (Written entries) must be made in black ink and in legible handwriting.
  2. Must be signed or contain a unique staff identifier in the case of electronic records. In the case of written records, the person’s name and job title must be printed alongside the first entry, for example, on a document signature recognition register.
  3. Made in error must be identified with a single line strike through, and the name, job title, signature of the nurse/midwife making the record, with the date and time of strikethrough, must be recorded in the original document.
  4. Made as an alteration or addition should be identified by the name, job title, and signature of the nurse/midwife recording the alteration or addition, and the date and time of alteration/addition.
  5. Must be made in records with a clearly identified unique patient number on each separate element.

   

  Entries to patient/client records made by pre-registration nursing or midwifery students:

       6. Must be countersigned by a registered nurse/ midwife.

  Entries to patient/client records made by Nursing Assistants (view the Recording Keeping Framework for Nursing Assistants here):

        7. Must be countersigned by a registered nurse/ midwife if the HCSW framework has not been undertaken or has not successfully been completed.