Nursing and Midwifery Directorate

Document Control Document: NHS Tayside Policy for Records and Record Keeping for Nursing and Midwifery Staff

Version: 4 Version Date: October 2019

Policy Manager: Charlie Sinclair, Associate Nurse Director

of 50 Review Date: October 2022

Nursing and Midwifery Directorate

Policy for Records and Record Keeping for Nursing and

Midwifery Staff

Policy Manager Charlie Sinclair

Policy Group Documentation Review Group

Policy Established July 2011

Policy Review Period/Expi ry October 2022

Last Updated October 2019

This policy does not apply to Medical/Dental Staff (delete as appropriate)

UNCONTROLLED WHEN PRINTED





Version Control

Version Number

Purpose/Change Author Date

1.0

Version Control was introduced in July 2011 and the previous versions of this policy, prior to this date, are available in the Electronic Document Store.

Eileen McKenna, Joan Wilson, Gail Smith, Lorna Wiggin, Gail Young

2.0 Policy review and update Audrey Fleming

October 2013

3.0

Policy review and update in line with NMC, The Code (2015) and updated records audit tool and standing operating procedures/ comments from Clinical Quality Forum ( 14th September 2015)

Audrey Fleming /Victoria Hampson

October 2015

3.1 Further review from expert consultation with Nursing and Midwifery Directorate and Heads of Nursing

Audrey Fleming/Victoria Hampson

December 2015– January 2016

3.2 Universal consultation - SCNs Audrey Fleming/Victoria Hampson

February 2016- May 2016

3.3 Review by Documentation Review Steering Group

Charlie Sinclair and members of the Documentation Review Steering Group

February 2019

4 Review by Documentation Review Steering Group Audit tool revised to evidence meeting national standards e.g. Older People Standards (HIS)

Charlie Sinclair and members of the Documentation Review Steering Group

September 2019





Contents Page number 1. Purpose and Scope 4

2. Statement of Policy 4 - 9

3. Roles and Responsibilities 9 - 10 4. Organisational Arrangements 10 5. Key Contacts 10 6. References & Bibliography 10 - 11 Appendix 1: Nursing and Midwifery Record Keeping Standards Audit Tool 12 - 16 Appendix 2 : Pre-Birth to Pre-School Records and Service Audit Tool 17 - 21 Appendix 3: School Aged Child Records and Service Audit Tool 22 - 24 Appendix 4 : Policy Approval Checklist 25 Appendix 5 : Equality Impact Assessment 26 - 36 Appendix 6: Training Plan 37 - 38





1. Purpose and Scope

The policy describes the professional standards of practice for all nurses and midwives relating to record keeping. It is concerned with the content and quality of health records and for ensuring that records provide a contemporaneous and complete record of care and is an adjunct to the NHS Tayside Health Records Management policy (2019) Health Records Management V4.2 Mar 19 - Mar 21.

The Policy aims to:-

1. Define the standards and principles for nursing and midwifery record keeping and to provide a framework for monitoring compliance with the standards

2. Provide guidance for registered nurses, midwives, nursing students and health care support workers within NHS Tayside to support them to achieve a consistent and high quality approach to record keeping.

Record keeping is an essential aspect of health care delivery and as such, is explicit within the Nursing & Midwifery Council (NMC) Code of Conduct, section 10 (2015) and also within the Code of Conduct for Healthcare Support Workers 2009 (section 4, sub section 4.1.6).

This includes but is not limited to patient records and includes all records that are relevant to the individual’s scope of practice.

Nurses and midwives requiring further clarification should refer to the NMC Code of Professional Conduct, Standards for conduct, performance and ethics (NMC, 2015). This policy provides guidance on the general principles of good record keeping, whilst acknowledging there may be speciality specific considerations. In these instances local Standard Operating Procedures for record keeping should be developed, approved through clinical governance structures and implemented. The Governance framework to support document control and approval is currently being developed. At time of writing it is proposed that any new document being developed or amended should be submitted to the Documentation Review Steering Group through the Nursing and Midwifery Directorate ([email protected]). For further information see section 2.11 ‘Governance of records’. Whilst this list is not exhaustive, records include all documentation relating to the patient such as:

• Treatment/observation charts including Centile Charts • Communication books/ward diaries • Ward dependency records/safety briefs • Clinical incident reporting forms (DATIX) • Clinical diaries • Theatre registers • Plans of care • Electronic care records • Multidisciplinary care pathways/records • Patient Held Records (Personal Child Health Record, Scottish Woman Held Maternity Record

(SWHMR)

2. Statement of Policy 2.1. Accountability and Delegation

All registered nurses and midwives working within NHS Tayside are accountable for commencing and maintaining accurate, comprehensive, contemporaneous and concise health care records regarding

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the care of patients/clients, inclusive of continuous charts, e.g., Fluid Balance Charts, 3 Day Food Record charts, Care Round/Skin Chart, National Early Warning Score (NEWS) Chart, Paediatric Early Warning Score (PEWS), etc and the SWHMR.

Record keeping can be undertaken by health care support workers (HCSWs) in line with the Code of Conduct for Healthcare Support Workers (2009) as long as training is completed, competency has been determined by a registered nurse/midwife and it is in the best interests of the patient. This allows HCSWs to document the care they have provided. Should these criteria be met, the registered nurse/midwife does not need to countersign the record entry and should not record details of care/countersign for care that they have neither witnessed nor can verify took place. If a HCSW is carrying out delegated care but is not deemed competent in record keeping, the registered nurse or midwife must make certain she is content with the care that has been delivered and that it is recorded. Countersignature and supervision should be undertaken by the registered nurse/midwife until the HCSW is deemed competent, (RCN, 2012). Student nurses and student midwives are required to have any entries they make to a patient record countersigned in line with the requirements of the NMC Standards for Education (2019).

2.2. Rationale The rationale for keeping accurate nursing & midwifery records are many and include:

• Serving as a tool to provide a full and accurate account of assessment, treatment, care planning and evaluation of care.

• Providing evidence of evaluation of the care given and the patient/client response to treatment/care.

• Promoting the ability to detect problems, such as changes or deterioration in the patient’s or client’s condition, at an early stage.

• Providing a tool for communication between the patient, the healthcare professional and/or other professionals involved in the care of the patient/client.

• Providing a tool for communication with family, carers and friends. • Assisting in the provision of continuity of care as a means of communication between all parties. • Demonstrating person centred care ensuring that patient/client and significant others, where

applicable, have been involved in discussion and decisions regarding the planning of care and its delivery.

• Providing a vital means of enhancing patient and staff safety, for example, through safety brief.

2.3. Frequency of Entries Frequency of entries should be at least once per shift for inpatient care or for each contact for those seen either in the Emergency Department or as an outpatient. More frequent entries are required when patients are

• nursed in the acute setting • have complex care needs when there is a change in the patient’s condition • benefitted when the record reflects multi-agency information sharing • requiring more intensive input or the patient’s clinical condition changes or deteriorates • identified as having care needs or mental health assessment giving cause for concern.

The NMC Code (2015) states “Records should be completed at the time or as soon as possible after an event”. It is therefore recommended that entries in records are not left to the end of a shift and are written as frequently as dictated by care delivery and changes in the patient’s well-being.





If important information has been omitted this can be included at a later time as long as it is recorded that it has been written retrospectively and the line manager informed. In community settings or in home settings documentation entries should be on the day of contact. This may only be relaxed in exceptional circumstances where this is not practicable e.g., it is impossible for the Registrant to access an electronic system in order to update the patient’s record. In such cases, the record must be completed at the earliest opportunity and in line with local Standard Operating Procedures which support a robust assessment of risk in each case.

Registrants should make every effort to access electronic records at any NHS Tayside facility if it is not feasible to return to their base. The best practice is where there is risk; the record is updated the same day regardless of constraints; however some flexibility is acceptable for the recording of routine interventions/visits.

2.4. Content and Style

In order to create and keep health records which are of the required standard for statutory, legal, business and professional requirements, patient/client records must always:

• Be factual, consistent and accurate. Information recorded about the patient should be written at the time of the event/care given or as soon as possible after to provide a chronological and accurate record of care and condition of the patient or client. It should be recorded if the notes are written some time after the event.

• Be written legibly using indelible ink, not pencil and a colour that can be photocopied, preferably black ink.

• Signatures/initials must be identifiable. • Have the patient’s name, Community Health Index number (CHI), and date of birth on each

single page or on the first page of a bound booklet. • Have the date and time of entry recorded and signed. • Ensure any alteration is made by scoring out with a single line and initialled, dated and timed

when the correction was made. If the record used does not contain a register of names and job titles of contributors, these must be provided in full beside the alteration – initials will not suffice.

• Ensure additions to existing entries are individually dated, timed and signed. • Be free of jargon, meaningless phrases, irrelevant speculation or offensive, subjective

statements. • Only use abbreviations or acronyms that have been approved.

All records must include the following:

• Clear evidence of care required, assessment, care planning, interventions and evaluation of care and patient/client response.

• Documentation of any changes in patient condition that arise and any action which may be required to be taken in response. This includes specific instances when retrospective information will require to be documented.

• The chronology of events and the reasons for any decisions made. • Details of the discussions you have with patients, carers and family members or other health

professionals. • A record of any known allergies or alerts on admission or any the patient/client may experience

during their period of care. • Person-centred considerations e.g. personal goals/preferences

Patient records maintained by nurses and midwifes should focus on the patient and not reflect external factors, e.g., staffing levels, time constraints, subjective statements about other members of staff. Where this may affect the individual ability to uphold the values of the Code, the Code says that:





“You must put the interests of people using or needing nursing or midwifery services first. You must make their care and safety your main concern and make sure that their dignity is preserved”. It also means that you have a professional duty to act or speak out if quality and safety may be compromised: you must act without delay if you believe that there is a risk to patient safety or public protection and if necessary, escalate any concerns to the appropriate line manager you may have about patient or public safety, or the level of care people are receiving in your workplace or any other healthcare setting and use the channels available to you in line with NMC guidance (2015) and NHS Tayside local working practices. Recording adverse events relating to violence and aggression The recording of an entry, relating to violence and aggression, into the patient’s record and the Datix system should be an accurate, factual reflection of the event. Therefore, recording instances of direct verbatim speech within quotation marks to record an abusive or threatening event which is intended to offend, intimidate, or cause emotional or psychological harm is acceptable. Verbatim recoding is acceptable in the context of NHS Tayside Information Governance as otherwise altering what is said or summarising may alter the true context of the words, and introduce greater subjectivity. However, offensive language should not be used to describe the situation or event. Supporting Additional Record Keeping Tools and Guidance

• Nursing and Midwifery Record Keeping Standards Audi t Tool , Appendix 1 • Pre-Birth to Pre-School Records & Service Audit Too l, Appendix 2. To view document, please

click here • School Aged Child Records & Service Audit Tool, App endix 3. To view document, please

click here

2.5. Person Centred Records

Records must be written whenever possible with the involvement of the patient, client or their legal Guardian/Power of Attorney/carer (if applicable) and should be written in terms which they can understand. Where relevant, patient/client related information may be recorded in a patient-held record or in the case of children, the Personal Child Health Record (PCHR) also known as the Red Book. When in exceptional circumstances it is deemed not safe or appropriate to leave the records in the patient’s/client’s home, the records should be kept at the practitioner’s work base. Any such arrangement should be clearly communicated with the team.

2.6. Electronic/Computer Held Nursing and Midwifery Records

Computer-held records are being used more frequently across NHS Tayside. Computer-held records can be easier to read, less bulky, reduce the need for duplication and increase communication across the inter-professional health care team.

Registered nurses and midwives should make themselves aware of any systems that are a requirement for them to use to communicate and record delivery of care and ensure they know how to use them effectively.

The same basic principles that apply to paper records must be applied to computer-held records. They should aid communication within the team, not replace the need to maintain dialogue. Safeguards for computer-held records must comply with the Computer Misuse Act 1990. The principles of confidentiality of information apply to computer (and faxed) records as all other records. Registered nurses and midwives are professionally accountable for ensuring that whatever system is used is fully secure. Patients should be involved in computer generated records in the same way as they are for paper records.

Registered nurses and midwives are accountable for any entry they make to a computer-held record and must ensure that any entry made is clearly identifiable and attributable to the person making the entry.

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Staff using electronic records should refer to local guidance for more detailed information.

2.7. Access to Electronic Records

Where nurses and midwives use electronic records they must use their personal staff password to access the system, such passwords must not be shared and should be guarded in line with NHS Tayside policies and procedures. The use of staff passwords for entries in electronic records ensures that there is an audit trail for when a record has been accessed and by whom. This also applies to HCSWs, assistant practitioners, early years workers and paediatric home support workers who may access and record care given in electronic records. It remains the responsibly of the registered nurse or midwife to ensure appropriate delegation and to assess competency of the staff member.

2.8. Legal Matters and Complaints

Nursing & midwifery records, diaries, birth plans and anything that makes reference to the care of the patient or client may be required as evidence to investigate a complaint, adverse or criminal incident or by the NMC Fitness to Practice Committee.

In negligence and malpractice law, the nursing records would be used as the most reliable source of evidence regarding quality of nursing care delivered. It is a part of the Health Record which is used as legal evidence of treatment. As often a significant period of time has passed and an individual’s recall may not be as dependable, accurate record keeping may protect against a lawsuit (Dimmond 2011).

2.9. Access to health records

The registered nurse or midwife should be aware that any entries made in a patient record may be scrutinised. Patients have a legal right to see their records and where possible should be involved in their content and may, as with SWHMR or Single Shared Assessment Plans (SSA), hold their own records.

The Data Protection Act (2018) governs access to health records for patients (whether paper or computerised) and the Access to Health Records Act (1990) governs access to deceased patients’ records. The Data Protection Act (1998) regulates storage and protection of patients’ records and also patients’ rights to have inaccurate information corrected. (See NHS Tayside Information Governance Policy 2016, NHS Tayside Information Security Policy (2016) and NHS Tayside Health Records Management Policy (2019))

2.10. Safe storage of records

NHS Tayside has a duty to ensure safe storage of records for patients. The details of this can be found within NHS Tayside’s Health Records Management Policy (2019). The organisation and individuals within NHS Tayside have a legal obligation to protect the confidentiality of the patient record. The patient record may contain clinical photographs and audio/video recordings where appropriate. Diaries or other methods of records in which patient identifiable information is held, must also be safely stored.

With reference to patient held records, patients should be informed of the purpose and importance of the record and their responsibility for its safe keeping. These principles apply to parent held records as well. In addition patient records may in certain circumstances be used for research, teaching and clinical supervision. The principles of access and confidentiality remain the same and the right of the patient to refuse access to their records should be respected. The use of patient records in research requires approval from the East of Scotland Research Ethics Service and will require to align to the Health Research Authority Standards. In some cases, nurses and midwives should be aware that they may need to seek permission through the Caldicott Guardian.





When visiting patients at home or in a community setting, patient records should not be left unattended, e.g., left in cars, and be returned to the work base at the end of each working day. However where this is not practical, records must be returned within 24 hours and staff must ensure that whilst away from the work base that patient records are stored safely and securely in their own home. The detail of how this is accomplished should be agreed locally whilst remaining compliant with NHS Tayside’s Health Records Policy (2019).

On the patient’s discharge or transfer all related documents must be collated and filed correctly in the patient’s healthcare records before the record leaves the ward/department. Where records are held in the patient’s home, it is the Registered Nurses’ responsibility to ensure that they are retrieved from the home at the end of an episode of care, on discharge or upon the death of the patient.

2.11. Governance of records

Good practice and clinical governance requires all records to have standardised formatting and to be of a good quality, i.e. not photocopied. In addition all records are required to have a Tayside Health Board (THB) number assigned.

To ensure that governance requirements are met, to reduce duplication of records and to ensure standardisation across NHS Tayside, an algorithm has been developed to support staff (including nurses and midwives) when developing or reviewing a clinical document. The algorithm is signposted from the NHS Tayside Policy Development, Review and Control Policy (2017). NHS Tayside will not recognise documentation that has not been approved through a recognised governance route and may not be recognised as an official document.

2.12. Training and Development

Record keeping is an essential aspect of health care delivery and as such, is explicit within the Nursing & Midwifery Council (NMC) Code (2015), and all registered nurses, midwives and health visitors should reflect on their own record keeping practice.

Arrangements to update nurses and midwives on record keeping should be provided locally based on identified service need and may include ensuring staff have access to online resources, e.g., NHS Education for Scotland Effective Practitioner. Nurses and Midwives may consider evidencing education and updates through their professional revalidation processes.

Record keeping is identified as a core competency for registrants and as such an assessment of skills and knowledge is incorporated within the local Adult In-Patient Core Nursing Competency Profile for Registered Nurses. This intends to set out clear expectations on the standard of record keeping required of registrants joining our organisation and how competence will be ascertained.

Core Competency Booklet for Non-registered Staff

Healthcare Support Workers, Midwifery Assistants, Assistant Practitioners and Paediatric Healthcare Support Workers must agree with their line manager that record keeping is a required skill and have this reflected in their Personal Development Plan. In addition they must also successfully complete the NHS Tayside HCSW formal training programme/workbook. This must include mentorship from a registered nurse and the HCSW must be deemed competent in both theory and practice before they are able to undertake record keeping.

3. Responsibilities

Nurse Director:

The Nurse Director is responsible for ensuring that this policy is reviewed and if necessary revised in the light of legislative guidance or organisational change. Review shall be at intervals of no greater than 3 years.

All professional leads, heads of service, line managers in each area are responsible for:





• Ensuring that staff have access to and comply with this policy. • Implementing agreed training or education methods/programmes to support the implementation

and adherence to this policy. • Notifying the Nurse Director should any revision to this policy be required out with set review

dates.

All NHS Tayside nursing and midwifery staff, including temporary and agency staff are responsible for:

• Compliance with this policy, procedures and supporting documents. • Co-operating with the development, implementation and review of the policy as part of their

normal duties and responsibilities. • Identifying the need for change in policy as a result of becoming aware of changes in practice,

changes to statutory requirements, revised professional or clinical standards and local/national directives and advising their line manager accordingly.

• Identifying training needs in respect of the policy and procedures and bringing them to the attention of their line manager.

• Taking necessary steps to address any knowledge/practice deficits in relation to this policy in line with professional accountability

4. Organisational Arrangements 4.1 Monitoring and Review

For all NHS Tayside nursing and midwifery records, the Nursing and Midwifery Record Keeping Standards Audit Tool, (Appendix 1), is used to audit record keeping standards. Five nursing records should be selected at random on a monthly basis and compliance reported through operational governance structures, then through Quality and Performance Reviews or equivalent mechanisms for Health and Social Care Partnerships. Other audit of Healthcare Records may also be undertaken in relation to Healthcare Improvement Scotland and other national inspection requirements e.g. Care of Older People in Hospital standards (2015) and Health and Social Care Standards (2017).

4.2 Improvement and Assurance

In response to audit results, each area will identify areas of good practice and areas for improvement. Improvement plans will be developed/updated and implemented following each audit cycle using improvement methodology. Learning and changes in practice will be shared within the organisation and across other forums where appropriate e.g. scheduled Quality and Performance Reviews or equivalent. Support to improve practice should be given and monitoring of improvement undertaken. It is the responsibility of the Senior Charge Nurse/Team Leader to ensure that this takes place. In addition, the appropriate line manager must be informed of the standards of record keeping within their area and made aware of any professional issues arising from these.

Significant concerns regarding the documentation/where documentation is incomplete must be fed back to staff to action as soon as possible after the audit has been completed.

5. Key Contacts

Documentation Review Steering Group (Nursing and Midwifery Directorate)

6. References and Bibliography

Dimmond, B. (2011) Legal Aspects of Nursing and healthcare, Pearson Education; 6th edition

Data Protection Act (2018) The Home Office Norwich: The Stationery Office www.hmso-gov.uk

http://www.hmso-gov.uk/





Department of Health (1990) Access to Health Records Act (1990) Department of Health Norwich: The Stationery Office www.hmso-gov.uk Department of Health (1997) Caldicott Report: The Stationery Office www.hmso-gov.uk

Freedom of Information Act (2000) The Home Office: The Stationery Office www.hmso-gov.uk

Human Rights Act (2000) The Home Office: The Stationery Office www.hmso-gov.uk

NHS Education for Scotland (2010) A Guide to Health Care Support Workers Education and Role Development www.nes.scot.nhs.uk

NHS Scotland (2009) Code of Conduct for Healthcare Support Workers www.scotland.gov.uk

NHS Tayside (2015) Health Records Strategy and Management Policy

NMC (2015) Briefing, Appropriate staffing in health and care settings: www.nmc.org.uk/ safe-staffing-position-statement Nursing & Midwifery Council (2015) The Code; Professional Standards of Practice and Behaviour for Nurses and Midwives London: NMC www.nmc-uk.org/The-revised-Code http://www.nmc-uk.org/

Royal College of Nursing (2012) Delegating record keeping and countersigning records. Guidance for nursing staff London: RCN www.rcn.org.uk Government of the United Kingdom (1998) Computer Misuse Act. The Home Office Norwich: The Stationery Office www.hmso-gov.uk





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../../csinclair5.TNHS/AppData/Local/Microsoft/Windows/Temporary Internet Files/tormerod/AppData/Local/Microsoft/Windows/Temporary Internet Files/afleming1/AppData/Roaming/Microsoft/Word/www.nmc.org.uk/ safe-staffing-position-statement

../../csinclair5.TNHS/AppData/Local/Microsoft/Windows/Temporary Internet Files/tormerod/AppData/Local/Microsoft/Windows/Temporary Internet Files/afleming1/AppData/Roaming/Microsoft/Word/www.nmc.org.uk/ safe-staffing-position-statement

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http://www.nmc-uk.org/

http://www.rcn.org.uk/






Appendix 1

Nursing and Midwifery Record Keeping Standards Audi t Tool

Date of Audit

Ward/ Clinical Area

Directorate

Name of Auditor(s)

Designation of Auditor(s)

Signature of Auditor(s)

Please allocate 2 hours to complete the audit Criteria for Audit: Choose 5 records at random to audit every month

Audit should be undertaken by the Senior Charge Nurse/Team Lead, or be delegated to a registered nurse/midwife

Only audit records completed whilst the patient is in your care (sample the admitting documentation and/or at least 6 other care episodes/shifts)

If applicable, for each record sampled include a sample from at least 3 additional charts e.g. Early Warning Score chart, Fluid Balance chart, SKIN/Care Round chart, specific care/ risk assessments At the end of the audit, record the overall compliance

Significant concerns regarding the documentation/wh ere documentation is incomplete must be fed back to staff to action as soon as possible after t he audit. Lead Nurses and Senior Nurses will review and monitor compliance with Senior Charge Nurses (or equivalent) as part of care assurance frameworks

N.B. For Acute Settings: On the allocated month whe re the Health Records Audit Tool is used the Monthly Case Note Review Tool can be o mitted





A. Identification Data

A1. The health record should contain the following :

Yes No N/A The patient/client’s full name on each single sheet or within each booklet.

The patient/client’s Date of Birth and CHI recorded on each single sheet or booklet.

For in-patients only

A patient Identity Band is in place and contains the following: Forename Surname Date of birth Community Hospital index (CHI) number Gender

A2. The admitting booklet/front page/initial assess ment should also include the following:

Yes No N/A

Full address Temporary Address (if applicable) Patient/client Telephone Number (if applicable) Religion/Ethnic Origin/Group Patients Preferred Name General Practitioner’s Name/Practice General Practitioner’s Address General Practitioner’s Telephone Number Date of Admission/First Contact with the service or transfer to ward/hospital Patients Gender Patients First Language/Communication needs Name and Contact Details for patients First Contact

Comments





B. Evidence of Accurate Record Keeping

B1. Yes No Is the record of care free from meaningless phrases, statements or inaccurate measures? (e.g. poor /large / small / fair, sips, skin intact, catheter patent and draining) Is the record free from irrelevant speculation or offensive subjective statements? (e.g. record describes a patient as drunk without providing evidence of their alcohol level, record documents opinions or assumptions. e.g. “had a good day,” “appears confused”, “pleasantly confused”, “slept well”, “demanding”, “difficult”, “challenging”) Is the record is free from unauthorised abbreviations?

C. Legibility of the Records C1. Yes No N/A All entries are legible. There are no errors such as typing or spelling mistakes. All entries are unambiguous and transparent to all document users.

Comments

Comments





Yes No N/A For written documentation only: All entries are written in indelible ink (Preferably black ink) The record is free from photocopied sheets The record is free from blank spaces/ gaps between entries Any alterations made to the record have been scored through with a single line Any alterations made to the record have been initialled Any alterations made to the record are dated and timed for when the correction was made

D. Dates and Signatures D1. Yes No N/A All entries are dated All entries are timed using the 24 hour clock All entries are signed or initialled Entries by non-registered staff have been countersigned by a registered professional, where appropriate

E. Chronological Order E1. Yes No Does the record provide a chronological account of the patient/client’s care and progress? (Entries are documented in correct date order) Have all entries been made as soon as possible after care has been given/care event occurred?

Comments

Comments





Audit Compliance Number of YES & N/A answers _______________________________ x 100 Number of questions - 37 Overall Compliance = _____________%

Comments





Appendix 2

Pre-Birth to Pre-School Records & Service Audit Too l

Date of Audit: Name of Auditor: DOB/CHI: Record No.: Name of Practitioner: GP Practice:

Audit Criteria: See Record Audit Tool Guidance

Criteria for Audit Yes No N/A

Child's Record

1 a) Primary visit undertaken within 11 - 14 days?

b) Was the GIRFEC Health Assessment

(GHA) initiated at primary visit?

c) Has an infant feeding assessment been completed?

2 a) Have two home visits been undertaken between 3 - 5 Weeks? If NO, specify reason.

b) Has a home visit been undertaken at

6 - 8 weeks?

3 a) Has the GHA been appropriately completed in all areas?

b) If a transfer in, has the GHA been

appropriately completed in all areas?

4 a) Has a Health Plan Indicator (HPI) been allocated by 11-14 days?

b) Has the HPI been updated by 6-8 weeks?

c) Has the HPI been confirmed by 6 months?

5

a) Is there evidence that the GHA has been reviewed at 6 months?

b) Has the GHA been updated following key

contact points in Pathway?

c) Has the GHA been updated following a

Significant Event?





Child Well -Being / Protection Criteria

6 Are there Child Protection (CP) concerns. If Yes: a) Does the GHA show assessment of risk,

analysis, intervention and plan in place to protect child?

b) Has the intervention and plan in place to

protect the child recorded within the GHA been reviewed and updated?

c) Are there updated Child Protection reports

attached in Service Core Forms?

d) If the child on the Child Protection Register

(CPR) is there a CP Plan in place?

e) If on the CPR has the Child been seen as

per Health Plan?

7 If the child a Looked After Child (LAC):

a) Is the LAC status recorded?

b) Is there a LAC Health Assessment?

c) Was this completed within 4 weeks of

notification of LAC status?

d) If over 4 years of age was their mental

health assessed using SDQ Tool?

8 Is the purpose of each visit recorded?

9 Is there a record of liaison and communication with other health and partner agencies e.g. Social Work, Midwife, GP.

10 The content of the Child's record is relevant to

the Child's health / well-being?

11 Is Subjective Objective Action Assessment Plan (SOAAP) being used?

12 Has there been a home visit at: a) 3 Months

b) 4 Months c) 8 Months

13 Has a Child Health Review been undertaken at: a) 6 - 8 Weeks

b) 13 - 15 Months

c) 27 - 30 Months

d) 4 - 5 Years

14 Is there a record of transfer to Named Person in Education between 4 - 5 ½ years?





15 a) Is there a Chronology of Significant Events?

b) Does the Chronology provide an overview

of the Child's circumstances?

c) Does the Chronology provide impact /

outcome of the significant event on child?

16 a) Is the Demographic page up to date?

b) Is there a record of all associated persons

and professionals involved?

17 Is the Ethnicity of the Child recorded?

18 Is there a Lone Working Risk Assessment in

place?

19 Abbreviations noted within the record correlate with the "Approved Abbreviation Sheet" as per Tayside Record Keeping Guidelines?

20 Are all records of client contact/interventions

recorded on day of contact or next working day?

21 Is there evidence of Child / Young Person /

Family involvement and engagement in the assessment and plan of care. e.g. are the parent/carer/child views clear within the record?

22 Is there a record of identified health issues being followed up on subsequent visits / contacts?

23 Is there a record of discussion of the key

public health issues as per Universal Pathway: a) Infant Feeding

b) Breast feeding

c) Smoking

d) Risk of sudden infant death

e) Risk of accidental head injury





Mother's Record 24 Is there a record of Pre-Birth contact visit at

32-34 weeks?

25 a) Has the 6 - 8 week Edinburgh Postnatal

Depression Scale (EPDS) been completed?

b) Has the 12 - 14 week (EPDS) been

completed?

26 Is there evidence of the Gender Based

Violence (GBV) Routine Enquiry being offered at: a) Initial Contact (if applicable)

b) If not applicable, has this been offered at

any subsequent contacts?

c) If GBV is present in the household are

there concerns regarding the mother/carer's ability to keep their child safe or the impact of GBV and has this been recorded in the GIRFEC Assessment?

Family Nurse Partnership Only

27 Enrolled on FNP Programme: a) Has the Date of Referral to Family Nurse

recorded?

b) Has the date when the client was

enrolled on the Programme been recorded?

28 Weekly Pregnancy visits for first 4 weeks on

Enrolment completed. Reason given if not visited.

29 Fortnightly Pregnancy visits until birth of baby.

Reason given if not visited.

30 If the young person / client is under 18 years

is there an up-to-date GIRFEC Health Assessment in place?

31 Has the Named Person been informed of any

wellbeing concerns identified by the Family Nurse for the young person / client?





Improvement Plan / Follow Up

Immediate Action Taken by Audito r Plan

Further Action Required Plan

Review Date

PART 1: Total YES’s added to Total NO’s = TOTAL NUMBER OF QUESTIONS ANSWERED PART 2: Total YES’s divided by Total Number of Question s Answered multiplied by 100 = %

Example 1: Part 1: 43 (YES’s) + 2 (NO’s) = 45 (Total Questions Answered)

Part 2: 43 (YES’s) / 45 (Total Number of Questions Answered) X 100 = 95%







Appendix 3

School Aged Child Records & Service Audit Tool

Date of Audit: Name of Auditor: DOB/CHI: AGE Record No.: Name of Practitioner: GP Practice:

Audit Criteria: See Record Audit Tool Guidance

Criteria for Audit Yes No N/A Action Required/Taken or

Comments

Child's Record

1 Is there a GIRFEC Health Assessment (GHA) in place?

2 a) Has the GHA been appropriately

completed in all areas for age of child?

b) If a transfer in, has the GHA been

appropriately completed in all areas?

3 a) Has a Health Plan Indicator (HPI) been

allocated for the child?

b) Has the HPI been updated following a

significant event e.g. Child Protection, Looked After Child.

4 Is there evidence that the GHA has been

reviewed / updated where a new health need has been identified?

Child Well -Being / Protection Criteria

5 Are there Child Protection (CP) concerns. If Yes: a) Does the GHA show assessment of risk,

analysis, intervention and plan in place to protect child?

b) Has the intervention and plan in place to

protect the child recorded within the GHA been reviewed and updated?

c) Are there updated Child Protection

reports attached in Service Core Forms?

d) If the child on the Child Protection

Register (CPR) is there a CP Plan in place?





e) If on the CPR has the Child been seen as per Child's Health Plan?

6 If the child a Looked After Child (LAC):

a) Is the LAC status recorded?

b) Is there a LAC Health Assessment?

c) Was this completed within 4 weeks of

notification of LAC status?

d) If over 4 years of age was their mental

health assessed using SDQ Tool?

7 Is the purpose of each visit/contact recorded?

8 Is there a record of liaison and communication with other health and partner agencies e.g. Social Work, GP, CAHMS

9 Is Subjective Objective Action Assessment

Plan (SOAAP) being used?

10

a) Is there a Chronology of Significant Events?

b) Does the chronology provide an overview

of the Child's circumstances?

c) Does the Chronology provide impact /

outcome of the significant event on child?

11 a) Is the Demographic page up to date?

b) Is there a record of all associated persons

and professionals involved?

12 Is there a Lone Working Risk Assessment in

place?

13 Is the Ethnicity of the Child recorded?

14 Abbreviations noted within the record correlate

with the "Approved Abbreviation Sheet" as per Tayside Record Keeping Guidelines?

15 Are all records of client contact/interventions

recorded on day of contact or next working day?

Records to be recorded on day of contact unless exceptional circumstances





16 Is there evidence of Child / Young Person / Family involvement and engagement in the assessment and plan of care? E.g. are the parent/carer/child views clear within the record?

17 Is there a record of identified issues being

followed up on subsequent visits / contacts?

Improvement Plan / Follow Up

Immediate Action Taken by A uditor Plan Date

Further Action Required Plan Date

Review Date

PART 1: Total YES’s added to Total NO’s = TOTAL NUMBER OF QUESTIONS ANSWERED

PART 2: Total YES’s divided by Total Number of Question s Answered multiplied by 100 = %









Appendix 4

NHS TAYSIDE – POLICY APPROVAL CHECKLIST

POLICY AREA: NURSING & MIDWIFERY DIRECTORATE POLICY TITLE: POLICY FOR RECORDS AND RECORD KEEPING FOR NURSING & MIDWIFERY STAFF POLICY MANAGER: EILEEN MCKENNA

Why has this policy been developed? To ensure a consistent and high quality approach to

record keeping practice by nurses and midwives. Has the policy been developed in accordance with or related to legislation? – Please give details of applicable legislation.

NMC (2015) The Code. Professional standards of practice and behaviour for nurses and midwives.

Has a risk control plan been developed and who is the owner of the risk? If not, why not?

No

Who has been involved/consulted in the development of the policy?

a) Expert consultation with Senior Practice Development Nurses, Heads of Nursing, Associate Nurse Directors, and the Nurse Director. b) Universal consultation with Senior Charge Nurses and their nursing teams

Has the policy been Equality Impact Assessed in relation to:- Has the policy been Equality Impact Assessed not to disadvantage the following groups:-

Age Disability Gender Reassignment Pregnancy/Maternity Race/Ethnicity Religion/Belief Sex (men and women) Sexual Orientation

Please indicate Yes/No for the following: Yes Yes Yes Yes Yes Yes Yes Yes

People with Mental Health Problems Homeless People People involved in the Criminal Justice System Staff Socio Economic Deprivation Groups Carers Literacy Rural Language/Social Origins

Please indicate Yes/No for the following: Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Does the policy contain evidence of the Equality Impact Assessment Process?

Yes

Is there an implementation plan?

Yes

Which officers are responsible for implementation?

Charlie Sinclair

When will the policy take effect? September 2019

Who must comply with the policy/strategy?

All nurses and midwives

How will they be informed of their responsibilities?

Directed to the policy via Nursing & Midwifery Forums

Is any training required?

Yes

If yes, attach a training plan

Are there any cost implications?

No

If yes, please detail costs and note source of funding

Who is responsible for auditing the implementation of the policy?

Senior Charge Nurses/ Team leads

What is the audit interval? Monthly using the Nursing (ADULT In- Patient) Case Note Review Tool and 6 monthly using the Nursing and Midwifery Record Keeping Standards Audit Tool

Who will receive the audit reports? Head of Nursing/Team leads, Directorate/CHP Management teams, Governance Groups

When will the policy be reviewed and provide details of policy review period (up to 5 years)

1-3 yearly

POLICY MANAGER: CHARLIE SINCLAIR DATE: SEPTEMBER 2019 APPROVAL COMMITTEE TO CONFIRM: CLINICAL QUALITY FORUM ADOPTION COMMITTEE TO CONFIRM: CARE GOVERNANCE COMMITTEE





APPENDIX 5 EQUALITY IMPACT ASSESSMENT Name of Policy, Service Improvement, Redesign or St rategy: Policy for Records and Record Keeping for Nursing and Midwifery Staff Lead Director of Manager: Sarah Dickie, Interim Nurse Director What are the main aims of the Policy, Service Impro vement, Redesign or Strategy? To provide a consistent and high quality approach to record keeping practice by nurses and midwives. Description of the Policy, Service Improvement, Red esign or Strategy – What is it? What does it do? Who does it? And wh o is it for? This policy provides guidance for all nurses and midwives on the standards of professional practice relating to record keeping and is mainly concerned with the content and quality of those records. What are the intended outcomes from the proposed Po licy, Service Improvement, Redesign or strategy? – What will happen as a result of it?- W ho benefits from it and how? A resource to guide nurses and midwives to achieve a consistent and high quality approach to record keeping and to provide a framework for monitoring compliance with recognised standards. Name of the group responsible for assessing or cons idering the equality impact assessment? This should be the Policy Working Group or the Project t eam for Service Improvement, Redesign or Strategy. Nursing & Midwifery Directorate

Document Control Document: Records and Record Keeping for Nursing and Midwifery Staff

Version: 4 Version Date: September 2019

Policy Manager: Charlie Sinclair Page: 27 of 50 Review Date: October 2020

Item Considerations of impact Explain the answer and if applicable detail the Impact

Document any Evidence/Research/Data to support the consideration of impact

Further Actions required

1.1 Will it impact on the whole population? Yes If yes will it have a differential impact on any of the groups identified in 1.2. If no go to 1.2 to identify which groups

All nursing and midwifery staff and all patients accessing services and provided with nursing interventions. No

1.2 Which of the protected characteristic(s) or groups will be affected?

• Minority ethnic population (including refugees, asylum seekers & gypsies/travellers)

• Women and men • People in religious/faith groups • Disabled people • Older people, children and young

people • Lesbian, gay, bisexual and

transgender people • People with mental health

problems • Homeless people • People involved in criminal

justice system • Staff • Socio- economically deprived

groups

N/A




SECTION 1 Part B – Equality and Diversity Impacts Which equality group or Protected Characteristics d o you think will be affected? Item Considerations of impact Explain the answer and if

applicable detail the Impact Document any Evidence/Research/Data to support the consideration of impact


1.3 Will the development of the policy, strategy or service improvement/redesign lead to

• Discrimination • Unequal opportunities • Poor relations between equality

groups and other groups • Other

No

SECTION 2 – Human Rights and Health Impact. Which Human Rights could be affected in relation to article 2, 3, 5, 6, 9 and 11. (ECHR: European Conv ention on Human Rights)




2.1

On Life (Article 2, ECHR) • Basic necessities such as adequate

nutrition, and safe drinking water • Suicide • Risk to life of / from others • Duties to protect life from risks by

self / others • End of life questions

No

2.2

On Freedom from ill -treatment (Article 3, ECHR) • Fear, humiliation • Intense physical or mental suffering

or anguish • Prevention of ill-treatment,

No







2.2 (cont) • Investigation of reasonably substantiated allegations of serious ill-treatment

• Dignified living conditions

2.3 On Liberty (Article 5, ECHR) • Detention under mental health law • Review of continued justification of

detention • Informing reasons for detention

No

2.4 On a Fair Hearing (Article 6, ECHR) • Staff disciplinary proceedings • Malpractice • Right to be heard • Procedural fairness • Effective participation in proceedings

that determine rights such as employment, damages / compensation

Yes. Contributes to available evidence to support a fair hearing.

2.5 On Pri vate and family life (Article 6, ECHR) • Private and Family life • Physical and moral integrity (e.g.

freedom from non-consensual treatment, harassment or abuse

• Personal data, privacy and confidentiality

• Sexual identity • Autonomy and self-determination • Relations with family, community

Yes. Contains details of patients’ private and family life where applicable and be subject to the confidentiality and data protection legislation as reflected in NHS Tayside Health Records Policy. Determines issues relating to capacity and patient/carer involvement.







2.5 (cont) • Participation in decisions that affect rights

• Legal capacity in decision making supported participation and decision making, accessible information and communication to support decision making

• Clean and healthy environment

2.6 On Freedom of thought, conscience and religion (Article 9, ECHR) • To express opinions and receive

and impart information and ideas without interference

Provides an opportunity to establish patient/carer involvement.

2.7 On Freedom of assembly and association (Article 11, ECHR) • Choosing whether to belong to a

trade union

N/A

2.8 On Marriage and founding a family • Capacity • Age

N/A

2.9 Protocol 1 (Article 1, 2, 3 ECHR) • Peaceful enjoyment of

possessions

N/A




SECTION 3 – Health Inequalities Impact Which health and lifestyle changes will be affected ?




3.1 What impact will the function, policy/strategy or service change have on lifestyles?

For example will the changes affect: • Diet & nutrition • Exercise & physical activity • Substance use: tobacco,

alcohol or drugs • Risk taking behaviours • Education & learning or skills • Other

Provides guidance to ensure consistent and high quality documentation of patient lifestyles and any resulting interventions.

3.2. Does your function, policy or service change consider the impact on the communities?

Things that might be affected include:

• Social status • Employment (paid/unpaid) • Social/family support • Stress • Income

No







3.3 Will the function, policy or service change have an impact on the physical environment? For example will there be impacts on:

• Living conditions • Working conditions • Pollution or climate change • Accidental injuries/public

safety • Transmission of infectious

diseases • Other

No

3.4 Will the function, policy or service change affect access to and experience of services? For example

• Healthcare • Social services • Education • Transport • Housing

No




SECTION 4 – Financial Decisions Impact How will it affect the financial decision or propos al?




3.5 In relation to the protected characteristics and groups identified: • What are the potential impacts on

health? • Will the function, policy or service

change impact on access to health care? If yes - in what way?

• Will the function or policy or service change impact on the experience of health care? If yes – in what way?

N/A

4.1

• Is the purpose of the financial decision for service improvement/redesign clearly set out

• Has the impact of your financial proposals on equality groups been thoroughly considered before any decisions are arrived at.

N/A

4.2 • Is there sufficient information to show that “due regard” has been paid to the equality duties in the financial decision making

• Have you identified methods for mitigating or avoiding any adverse impacts on equality groups

• Have those likely to be affected by the financial proposal been consulted and involved

N/A




Item Considerations of impact Explain the answer and if



5. Involvement, Consultation and Engagement (IEC) 1) What existing IEC data do we have?

• Existing IEC sources • Original IEC • Key learning

2) What further IEC, if any, do you need to undertake?

The first version of the policy was developed following a wide consultation. The amendments made during this review reflect updated, relevant professional guidance/policy and current local initiatives as determined by Senior Nurses within the Nursing & Midwifery Directorate. There are no significant changes to the key principles that formed the first version of the policy.

6. Have any potential negative impacts been identified?

• If so, what action has been proposed to counteract the negative impacts? (if yes state how)

For example: • Is there any unlawful

discrimination? • Could any community get an

adverse outcome? • Could any group be excluded

from the benefits of the function/policy?

(consider groups outlined in 1.2) • Does it reinforce negative

stereotypes? (For example, are any of the groups identified in 1.2 being disadvantaged due to perception rather than factual

No




information?) Item Considerations of impact Explain the answer and if



7. Data & Research • Is there need to gather

further evidence/data? • Are there any apparent gaps

in knowledge/skills?

The policy contains an audit tool in order to measure nursing records against agreed standards.

8. Monitoring of outcomes • How will the outcomes be

monitored? • Who will monitor? • What criteria will you use to

measure progress towards the outcomes?

By the SCN/Team leader. Through the use of the audit tools.

9. Recommendations State the conclusion of the Impact Assessment

The reviewed and updated policy has a positive impact on the population affected.

10. Completed function/policy • Who will sign this off? • When?

Presented to Clinical Quality Forum in July 2015 , September 2015 and March 2016 and Clinical and Care Governance Committee for approval in August 2015.

11. Publication

March 2016




Conclusion Sheet for Equality Impact Assessment

1. POSITIVE IMPACTS (NOTE THE GROUPS AFFECTED)

Provides a consistent and high quality approach to record keeping practice by nurses and midwives.

Records will be written whenever possible with the involvement of the patient/carer and should be written in terms they understand.

Nursing and midwifery records are factual, accurate and legible.

Education and monitoring of record keeping practice will be completed.

7. NEGATIVE IMPACTS (NOTE THE GROUPS

AFFECTED)

None

3. ADDITIONAL INFORMATION AND EVIDENCE REQUIRED

The NMC identifies record keeping as an integral part of nursing and midwifery practice and is

considers the record a tool for professional practice that should support the care process. 4. RECOMMENDATIONS

The audit tool incorporated in the policy is used to monitor practice in relation to nursing and midwifery records as part of continuous improvement efforts.

5. FROM THE OUTCOME OF THE RIC, HAVE NEGATIVE IMPAC TS BEEN IDENTIFIED FOR RACE OR OTHER

EQUALITY GROUPS? HAS A FULL EQIA PROCESS BEEN RECO MMENDED? IF NOT, WHY NOT? 5. FROM THE OUTCOME OF THE RIC, HAVE NEGATIVE IMPAC TS BEEN IDENTIFIED FOR RACE OR OTHER

EQUALITY GROUPS? HAS A FULL EQIA PROCESS BEEN RECO MMENDED? IF NOT, WHY NOT?

Manager’s Signature: Charlie Sinclair Date: September 2019


Version: 3.2 Version Date: September 2019


Appendix 6

POLICY INDICATIVE TRAINING PLAN

Level of Delivery/ Train ing Format of Delivery Target Groups

Level 1 eLearning All staff

Level 2 General raising awareness All staff

Level 3 ‘Behavioural skills’ toolkit training / Detailed training programme Line Managers

Level 4 Consultancy/Values based reflective practice / Coaching support from HR / OD Team Identified as required

Future course dates and availability are published on the Tayside Training Database and via electronic notice board, both accessed via Staffnet.


Version: 3.2 Version Date: September 2019


TOPIC Level

of training

Frequency / Dates of Training

Format of Delivery

Target Group

Quantifiable Resources

Links to eKSF Dimensions

Newly Qualified

Practitioner - Quality Record Keeping

Training

Record Keeping Competencies for

HCSWs

Record Keeping Core Competencies for

registrants

2 3 3

Annual

Attendance at 2 sessions (biannually)

Self Directed. On new appointment to the organisation/ad hoc to improve practice/

capability

Workshops

Series of Workshops, Theoretical

Workbook and Mentorship in

Practice

Competency Profile and Mentorship

Registered Nurses and Midwives

Health Care Assistants

All Registered Nurses and Midwives

Cost Neutral. Provided by

Nursing &Midwifery Directorate

Cost Neutral. Workshops provided by Nursing & Midwifery

Directorate, mentorship provided by Registered Nurses and Midwives in

clinical areas.

Cost neutral. Work based assessment, mentorship

and learning

Communication

Personal and People

Development Quality

Communication Personal and

People Development

Quality

Communication Personal and

People Development

Quality

Nursing and Midwifery Directorate

Documents

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