Recording Care – The Nursing Challenge 9th March 2016

‘In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison....’ Florence Nightingale 1863

Evidence Base Literature Review: Factors Influencing Quality of Registrant Record Keeping The Value and Purpose of Record Keeping Audit Information Recorded Competence to Record Professional Supervision Patient Awareness/ Inclusion Issues Related to Time

& ‘s “It ain’t what you do it’s the way that you do it, and that’s what get results…” X X

Recording Care 2009 - 2016 2009 2010 2011 2012/13 2014 2015 2016

Recording Care 2011 - 13 Aim: To implement an agreed Regional HSC Nursing Document, and improvement methodologies, tools and resources developed during the RRKI to facilitate improvement in the standard of nurse record keeping in Northern Ireland and to promote a culture which supports person-centred record keeping practices.

How? Work-based issues logs Partnership with Practice Time and Effort Improvement demonstrated in Practice Encouraging and engaging with teams

Outcomes Standards for Nursing and Midwifery Record Keeping Practice How √ Regional person-centred nursing assessment and plan of care document What √ Improved record keeping practice - 30% increase in audit scores Results!

Ongoing Work Endoscopy Day Case Record Under 24 hour stay record Children’s Record Learning Disabilities Record Care planning

Learning

Learning Regional Sign-up Leadership (Executive Nurse to Champion – CNO commission) Facilitation Listen to the frontline Clear goals Accountability Tenacity and Enthusiasm Value and mark achievement (Never give up)