Nursing and midwifery record keeping and documentation are fundamental to safe, effective and person‑centred care. This page includes key resources to support consistent, high‑quality documentation across all nursing and midwifery services in Northern Ireland. Central to this is the Person‑centred Standards for Nursing and Midwifery Documentation, supported by established record‑keeping frameworks and guidance on digital nursing and midwifery practice. Together, these resources support nurses and midwives to document care that is accurate, inclusive, professionally accountable and meaningful to those receiving care.
Regional Standards for Person Centred Nursing and Midwifery Documentation
The Person‑centred Standards for Nursing and Midwifery Documentation set out a clear and consistent approach to record keeping across written and digital environments. They place the person at the centre of every record and reflect professional accountability, clinical judgement and safe, effective care. The Standards align with the NMC Code, support quality improvement through assurance and audit, and recognise the increasing use of digital systems across health and social care in Northern Ireland. They can be accessed here
Resources
Digital Practice
The All-Ireland Digital Capabilities Framework was developed through a collaboration with NIPEC, Digital Health and Care NI, the office of the Nursing and Midwifery Services Director (ONMSD) Ireland, the Health Service Executive Ireland and the Australasian Institute for Digital Health.
The All-Ireland Digital Capabilities Framework for nursing and midwifery is the first release in a phased development plan which should eventually lead to production of a multi-professional digital capability framework for all professions in Ireland.
The document can be accessed here
PACE
‘PACE’ (Person-centred Assessment, Care planning and Evaluation) Framework was the product of a ‘ground up’ iterative process, that is used in conjunction with existing nursing practice theory, incorporating relevant risk assessments.
View or download the PACE leaflet