Improving Record Keeping Practice in Northern Ireland

The standard of record keeping within health professions has been the subject of much concern during the last decade. Northern Ireland Public Inquiries during 2004 – 2009  Recognised inaccurate record keeping practice as a particular failing of service provision. Themes arising from recommendations include incomplete records; information not recorded on admission, discharge and during an episode of care; and lack of evidence of patient and carer engagement.

Since 2009 under the commission of the Chief Nursing Officer for Northern Ireland, NIPEC has been taking forward a project, Chaired by Mr Alan Corry-Finn, Executive Director of Nursing, Western Health and Social Care Trust, the aim of which is to improve the standard of nurse record keeping practice in the region.

BACKGROUND

In Phase 1 of Recording Care the project oversaw the spread of improvement methodologies for record keeping practice for nursing and midwifery within acute care settings in Health and Social Care (HSC) Trusts, Northern Ireland. Outcomes of the Project an improvement of 30% in record keeping practice calculated via the NIPEC Online Audit Tool (NOAT) across 105 wards engaged in the Project from baseline to completion of a bespoke Practice Improvement Programme (PIP).

Central to the ability of the HSC organisation to complete this work was the deployment of five seconded Officers, one within each HSC organisation, who were tasked with the responsibility of effecting successful implementation of the tools and resources to support improvement in nurse record keeping practice over a 14 month timeframe.

In Phase 2, audit and improvement has continued to be reported across the region with further development of tools and resources.

The two documents can be viewed below.



NIPEC Officers managing this Project