1. Recording Care – The Nursing Challenge
9th March 2016

2. ‘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

3. 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

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

5. Recording Care
2009
2010
2011
2012/13
2014
2015
2016

6. Recording Care
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.

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

8. 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!

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

10. Learning

11. 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)