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).

The publication of the new NMC Code now provides an opportune context setting out standards and a clear expectation of the practice, behaviours and attitudes required from registrants. Revalidation processes, due to be launched in 2016, will for the first time require individual nurses and midwives to demonstrate through a range of evidential requirements that they are fit to practise against the standards of the Code.

It is in that context the Chief Nursing Officers (CNOs) working alongside the Nursing and Midwifery Council (NMC) will take forward a nationwide initiative to define what professionalism means in practice. The work is being Chaired by Professor Charlotte McArdle on behalf of the UK CNOs.

Return to Improving Record Keeping Practice in Northern Ireland

Documents

28th January 2016
Final Report Phase 1 April 2013
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18th July 2016
Systematic Review Report 2010
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