Nursing Content Standards Anne Casey FRCN Editor Paediatric Nursing Adviser in Informatics Standards, RCN Clinical Lead, NHS (England) Information Standards Board Member, SNOMED Content Committee

Nursing Content Standards? u These are the standards that a regulator (the NMC) would expect a registered nurse to conform to related to the content of a patient record or communication from it i.e. –The Professional / regulatory specification for the detail of what should be recorded about the nursing management of the patient, including content of communications

Can we learn from the RCP? Record programme – to April 08 u Generic standards for medical (hospital) records u Content of: –Acute medical admission ‘clerking’ –Discharge from hospital record (medical) –Doctor’s component of handover record

‘Record once, use many times’ u Not necessarily a ‘one to one’ match between clinical content item and secondary uses data item u Unless we get the content piece defined and into electronic record systems, nurses will still be expected to record for activity / costing analysis. For example: –The pick list of community nursing intervention terms will be at a higher level of abstraction than is needed for care: ‘daily wound dressing’ rather than ‘dress ulcer on right leg using xxx cream and yyy dressing’.

Two tasks for the profession 1. Define record content standards for safe and good quality care e.g. every adult patient admitted to hospital should have a falls risk assessment using xx validated assessment tool and the result should be recorded. uThis step provides the system developer with a professionally defined system requirement. 2. Define (separately) the data requirements to support specific secondary analyses such as audit of falls risk assessment outcomes etc. uIf we don’t complete the first task we are in danger of having the secondary requirements continuing to drive what nurses are expected to record.

Standard nursing terminology? u The NHS standard, multidisciplinary terminology for use in electronic records is SNOMED Clinical Terms (CT) u Terms from existing nursing terminologies are present in SNOMED CT u Existing nursing terminologies/classifications may be fit for purpose of recording / extracting data but until the requirements (see previous slide) are clear we cannot make that judgement.

What do we need (RCN)? u Process and infrastructure for appraising and endorsing content standards –RLI team are discussing u Generic process for developing, testing and maintaining content standards –RLI team are discussing u Projects to develop priority content standards –Much could be done by forums a la competency development but with better support u Capacity to participate in collaborative work –????