|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.
Phase 1 of Recording Care tested and amended a regional person centred nursing assessment and plan of care document for adult in-patient care settings in Northern Ireland.
Having reviewed the achievements of the first phase of the Recording Care Project, the Steering Group recommended that Phase 2 of the Project incorporate a work stream which would take forward mapping of the regional person centred nursing assessment and plan of care document with the record keeping system currently available in children’s care settings and reach regional agreement of a common system within this area.