Better nursing records for better nursing care

Better digital nursing records with consistent and standardised information that nurses can access in different care settings creates safer, better outcomes for people and gives nurses more time to care.

The PRSB has been commissioned by NHSX to develop national standardised nursing documentation and this month, PRSB nurse researchers and analysts hosted three focus groups  – for adult nurses, paediatric and young people nurses, and service-users – to inform this work.

Professional participants worked through four broad questions on the following topics: initial nursing assessments, information received from other care settings via a person’s record and involving people more in their nursing assessments. From the service-user perspective, attendees were asked to give their views on how they can participate in their own nursing assessments, what information they feel is most critical to include in their record for nurses’ use as well as their own self-management and understanding.

Paediatric nurses explained that as well as identifying the needs of the child and family, initial assessments often must look at how needs can be met within a school setting. One participant highlighted that nursing assessments should be transferrable to adult services because nurses do not have time to duplicate assessments that should already be available to them.

People expressed a range of views about what the most important information is for nursing records, including medications and historical information from their GP. Emma Robertson, co-lead on the project who has a wealth of experience of care, highlighted that environmental factors such as someone’s living situation, should be recorded and known in order to facilitate care. For example, how many flights of stairs someone has will impact how they receive care and how much help they may require post-treatment.

Although the nursing project is commissioned by the NHS in England, there is ongoing discussions and collaboration with the other three nations about digitising nursing records. The PRSB is working with colleagues in Scotland, Wales and Northern Ireland to ensure that this work is aligned with their own and that we are learning from their good practices.

For more information about the nursing records project and to get involved, please email info@theprsb.org.

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