Art & science leading better care series: 6
Better documentation improves patient care Kent P, Morrow K (2014) Better documentation improves patient care. Nursing Standard. 29, 14, 44-51. Date of submission: June 26 2014; date of acceptance: August 8 2014.
Abstract This article is the sixth in a series of seven describing the journey within NHS Lanarkshire in partnership with the University of the West of Scotland to support nursing and midwifery leadership roles through Scotland’s Leading Better Care programme. Preceding articles have provided an overview of the programme and discussed a range of staff development work programmes. This article describes work carried out on clinical documentation to promote delivery of the three quality ambitions of safe, effective and person-centred care.
Authors Patricia Kent Practice development practitioner, documentation, Practice Development Centre, NHS Lanarkshire, Hamilton, Scotland. Karen Morrow Practice development practitioner, acute care, Practice Development Centre, NHS Lanarkshire, Hamilton, Scotland. Correspondence to: [email protected]
Keywords Documentation, Leading Better Care, nursing care, nursing standards, patient care, quality improvement, record-keeping
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: rcnpublishing.com/r/author-guidelines
THE NURSING AND MIDWIFERY Council (NMC) (2010) asserts that good record-keeping is: ‘An integral part of nursing and midwifery practice, and is essential to the provision of safe and effective care. It is not an optional extra to be fitted in if circumstances allow.’ Good record-keeping depends on good documentation, and this article presents a number of initiatives undertaken by NHS Lanarkshire to improve the documentation used by nurses, midwives and allied health professionals (NMAHPs). The process of improving documentation has supported the implementation of Leading Better Care (LBC), a national policy for NHS Scotland, previously described by McGuire and Ray (2014).
Documentation issues A common issue highlighted in internal complaints and incident reports in NHS Lanarkshire, and in external reports, reviews and investigations, is poor record-keeping and care documentation. A review of the literature shows that below-standard documentation and record-keeping issues are not only local to NHS Lanarkshire but are also replicated across health services nationally and internationally (Laitinen et al 2010, Lees 2010, Asamani et al 2014). The Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust January 2005-March 2009 (Francis 2010) identified issues with record-keeping including incomplete and inconsistent nursing records, and deficiencies in recording discussions with patients and family. The report recommended that a note-keeping review should be performed (Francis 2010). The Scottish Public Services Ombudsman (SPSO) (2013), in the annual complaints report for health, cited communication as a major issue in complaints regarding health services. Reasons for these complaints include: communication between health professionals; communication between health professionals and patients; and care documentation and record-keeping. In regard to
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record-keeping issues, the SPSO (2014) states: ‘Good record-keeping is not a nice-to-have, it is an essential component of good care and good complaints handling.’ Other issues identified in NHS Lanarkshire include inaccurate and inconsistent documentation; inefficiencies in the use of documentation; an absence of governance in documentation development, implementation and review; and duplication of effort for staff, patients and carers. International studies concur, with Barthold (2009) describing unnecessary duplication of care records and a lack of evidence-based documentation and documentation standards, and Paans et al (2010) reporting inaccurate nursing documentation in the Netherlands. Studies in Sweden, New Zealand and Australia have identified a lack of clarity and difficulty in describing patient care, treatment and progress (Törnvall and Wilhelmsson 2008, Tranter 2009, Blair and Smith 2012). One NHS trust in England identified that its four hospital sites each had different sets of documentation (O’Connor et al 2007). Researchers have also highlighted difficulties in relation to the multipurpose nature of clinical documentation – records must confirm the prescription of treatment and care, offer a narrative of care and changing patient condition, and confirm what has been done to prove that the plan of care is fulfilled (Frank-Stromborg et al 2001, Austin 2010, Prideaux 2011). The suggestion is that this may contribute to issues with record-keeping and documenting care.
Components of good documentation In addition to highlighting issues with documentation, the literature offers suggestions for improvement. Structured documentation, including the use of a nursing model, documentation system or headings is recommended (Björvell et al 2002, Kaakinen and Torppa 2009, Prideaux 2011). Participants in a study conducted by Björvell et al (2003) commented that structured documentation made nurses think more and in a different way about their patient care. Structured documentation is also seen as important for the successful transfer of information from paper to electronic patient record systems (Prideaux 2011, Wang et al 2011). Electronic patient record systems have been shown to reduce the time spent documenting care, thus allowing more time with the patient, improving the quality of documentation and allowing easier auditing of practice. However, this should take place only with a fully supported implementation process and appropriate
technology (Barthold 2009, Prideaux 2011, Blair and Smith 2012). A meta-analysis by Jefferies et al (2010) identified seven essential components of quality nursing documentation (Box 1). Factors such as access to education programmes, improved nurse-to-patient ratios and a positive staff attitude were identified by Paans et al (2011) as being potentially beneficial for nursing documentation. Müller-Staub et al (2007) reported significant improvement in documenting nursing diagnoses (identification of problems), interventions and outcomes following staff education. The benefits of training on how to write clear records and regular auditing have been described (Johnston et al 2010, Jefferies et al 2012). Frank-Stromborg et al (2001) cited adhering to documentation guidelines and principles as essential for improving the accuracy of records and increasing the likelihood of improved patient care.
Documentation initiatives in NHS Lanarkshire The documentation work in NHS Lanarkshire was supported by the local NMAHP Practice Development Centre and in particular by the establishment of a practice development practitioner post for documentation. The following areas of work were prioritised: A review and rationalisation programme for existing documentation. Development of an infrastructure to support documentation control, management and quality assurance. Implementation of sets of standardised documentation appropriate in different care contexts.
Documentation review and rationalisation
In 2009, a review and standardisation of nursing documentation for the district nursing service
BOX 1 Seven essential components of quality nursing documentation Nursing documentation should: 1. Be patient centred. 2. Contain the actual work of nurses, including patient education and psychosocial support. 3. Be written to reflect the objective clinical judgement of the nurse. 4. Be presented in a logical and sequential manner. 5. Be written contemporaneously (as events occur). 6. Record variances in care within and beyond the healthcare record. 7. Fulfil legal requirements. (Adapted from Jefferies et al 2010)
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Art & science leading better care series: 6 were undertaken as precursors to a move to an electronic patient record. The review revealed that many documents were no longer fit for purpose, and this provided the impetus for a major assessment of all inpatient and outpatient documentation, which was performed in 2010. Paper and electronic documents were gathered from more than 130 areas in three acute district general hospitals, 12 associated hospitals (including mental health, learning disabilities and care of older people specialties) and four GP-led community hospitals. This resulted in a compilation of approximately 2,500 documents and identification of issues including: Documentation not reflecting evidence-based practice from guidelines, for example the Scottish Intercollegiate Guidelines Network (SIGN) (2014), and improvement programmes such as the Scottish Patient Safety Programme (2014) and the Person-Centred Health and Care Collaborative (Healthcare Improvement Scotland (HIS) 2014). A lack of clarity about when documents were created or by whom. Variations of the same type of document in use, creating confusion and resulting in the duplication of effort for staff and patients. Poor quality and supply of documentation, for example some were photocopied to the point of being almost illegible. The initial decision was to focus on inpatient services within the acute hospitals and to prioritise the 30 most commonly used or ‘standard’ documents in these services. These documents included charts such as those used for vital signs and fluid balance; assessments such as falls risk, pressure ulcer risk and mobility; and forms such as those for surgical procedures and legal matters. As mentioned earlier, there were several versions of documents, and a review of 122 documents was required. The scale of this work meant that it took until the end of 2011 to finalise the 30 standardised and evidenced-based documents. This process provided the opportunity to remove out-of-date documents and the rationalise the use of an external printing company, which allowed cost savings in the longer term. As part of the standardisation process, a one-day event took place in September 2012 to review all remaining acute care services documentation. Nurse representatives from all acute services met to review and decide on the potential use of these documents. This resulted in the overall documentation list being reduced from 516 to 410. A second documentation rationalisation event was held in
July 2013, reducing the number of documents further to 261.
Infrastructure to support documentation control, management and quality assurance
The documentation review process identified the need for a sustainable approach. Sustainability in health care is defined as: ‘when new ways of working and improved outcomes become the norm’ (NHS Scotland Quality Improvement Hub 2014). To achieve this, an NHS Lanarkshire-wide NMAHP Clinical Documentation Review Group was set up in 2011 with two main objectives: 1. To identify and implement a single system of quality control and governance for the development, ratification, implementation and review of NMAHP clinical documentation. 2. To set standards and principles for the format and content of NMAHP clinical documentation that reflect professional standards, caring and compassionate practice, values and evidence-based practice. The Clinical Documentation Review Group identified and commissioned 15 subgroups in which six specialty areas and nine allied health professional (AHP) departments would take responsibility for documentation in their own areas. With later developments it has grown to eight areas and ten AHP departments. A structure outlining reporting mechanisms to the subgroups and other relevant local and national groups was agreed (Figure 1). The Clinical Documentation Review Group’s initial work concentrated on the development of a documentation policy to incorporate standards and principles. This policy was based on World Health Organization (2007) guidelines and was launched in June 2012. It describes the desired attributes for NMAHP clinical documentation as: Clear. Concise. Complete. Correct. Consecutive. Contemporary. Confidential. Person-centred. Collaborative. Comprehensive. These components are set out in three guiding principles for documentation: Guiding Principle 1 – comprehensive and complete record. Guiding Principle 2 – person-centred and collaborative.
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Guiding Principle 3 – ensuring and maintaining confidentiality. The policy describes the system of quality control and governance for the development, ratification, implementation, review and supply of all NMAHP clinical documentation.
Implementation of sets of standardised documentation within different care contexts
The NMAHP Clinical Documentation Review Group’s policy states that ‘where appropriate, documentation will be standardised across NHS Lanarkshire’ (NHS Lanarkshire 2012) to reduce variation in practice and reflect a consistent approach to care for patients. Variation, either by organising the same thing in different ways, or by performing different tests for the same
condition, results in service delays (NHS Institute for Innovation and Improvement 2013a). In 2010, a UK-wide scoping exercise was undertaken by the NHS Lanarkshire acute care subgroup of the Clinical Documentation Review Group to identify areas of good practice in relation to documentation – that is, documentation that promotes person-centred care, is structured and reflects the nursing care process. The Gloucestershire Patient Profile from Gloucestershire Hospitals NHS Foundation Trust (2010) was selected and permission obtained to adapt it for use in Lanarkshire. In June 2011 a Nursing Care Record was produced based on the Roper, Logan and
FIGURE 1 Clinical Documentation Review Group reporting structure NHSL Clinical Governance Committee Other disciplines/agencies: Medicine Pharmacy Local authorities Managed clinical networks
Local clinical quality and governance groups
Acute care subgroup
Addictions subgroup
NMAHP Senior Leaders Group
Leading Better Care/Best Possible Start boards
NMAHP Clinical Documentation Review Group
Children and young persons’ service subgroup
Long-term conditions subgroup
Mental health and learning disabilities subgroup
Midwifery subgroup
Other local groups: Scottish Patient Safety Programme Person-Centred Health and Care Collaborative Service improvement boards MiDIS* TrakCare*
Neonatal subgroup
Public health subgroup
AHP Professional Leads Group
AHP subgroups: Audiology Dietetics Occupational therapy Orthoptics Orthotics and prosthetics
Physiotherapy Podiatry Radiography Speech and language therapy Spiritual care services
*Electronic information systems AHP = allied health professional, NHSL = NHS Lanarkshire, NMAHP = nursing, midwifery and allied health professional
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Art & science leading better care series: 6 Tierney model of nursing (Roper et al 2000). This was produced in booklet format since consultation with staff had identified that having everything in one place would reduce the risk of documentation not being completed and staff having to spend time sourcing documents. Contents included: Reason for the patient’s admission and goals of care. A systematic structure to record assessment of activities of living, and care planning, implementation and evaluation. Record of intentional rounding – care rounds or comfort rounds, which take place regularly to check patients’ needs (National Nursing Research Unit 2012). Record of communication with relatives and carers. The activities of living assessment also incorporated trigger questions in relation to best practice on pressure ulcer risk assessment (HIS 2011), falls risk assessment (National Institute for Health and Care Excellence 2004), and the peripheral vascular catheter insertion and maintenance care bundles (HIS 2013). Documentation testing was performed in June and July 2011 using the plan, do, study, act (PDSA) cycle (NHS Institute for Innovation and Improvement 2013b). The documentation was reviewed and the finalised version implemented between March and May 2012 together with guidance for staff and provision for ongoing audit. In November 2012, an online survey on the Nursing Care Record was distributed to all senior charge nurses, AHP leads and other relevant staff, for example infection control and tissue viability nurses. Approximately 100 staff were invited to respond, and there was a 40% response rate. The survey consisted of five questions: 1. Which specialty do you currently work in? 2. Have you used the Nursing Care Record? 3. Is the Nursing Care Record effective in demonstrating the individualised care needs of your patients? 4. Are further improvements required to the Nursing Care Record? 5. Please detail any other recommendations you have to assist in the review of the Nursing Care Record. A total of 67% of those who responded agreed that the Nursing Care Record was effective in demonstrating the individualised care needs of patients. However, the same percentage also stated that further improvements were required. Specifically, it was suggested that
more training was required to improve the consistency of completion and the layout of the Nursing Care Record needed to be amended to increase ease of use. In addition to incorporating the survey results into a further revised version of the documentation, it was important to reflect the wider initiatives in NHS Scotland. Features of the revised version included: Reason for patient admission and person-centred goals of care, including the five ‘Must Do with Me’ areas (Person-Centred Health and Care Collaborative 2013). Activities of living assessment, incorporating latest best practice regarding peripheral vascular catheter insertion, maintenance care bundles, falls risk and pressure ulcer risk assessments (HIS 2013). Care planning, implementation and evaluation (a multidisciplinary notes section for all staff), in addition to a record of communication with relatives and carers. Commonly used charts and assessments, for example the Malnutrition Universal Screening Tool, a mobility assessment and the Abbreviated Mental Test. As part of these changes and following consultation with staff, the documentation was renamed the Personal Care Record, and a test version was produced in June 2013. To assist the introduction of the Personal Care Record, support and guidance for staff within the testing and implementation phases were provided. Implementation was led by a group of band 5 staff nurses who had dual roles within practice development and clinical practice. They were supported by the NMAHP Practice Development Centre within the local LBC programme. This approach enabled consistency, communication and developmental support for all 80-plus ward areas. Feedback from these nurses suggested that support given to ward staff was more effective when it included Practice Development Centre staff working clinically with nurses while using the documentation. PDSA cycle testing was again used during implementation of the new record system, with the first cycle beginning on three wards at each acute hospital site in June 2013. On each ward one person was identified to link with the Practice Development Centre team, with tailored support being provided, such as one-to-one conversations, presentations and compilation of sample documents demonstrating good practice in record-keeping. This process lasted for
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a three-week period and, following feedback and evaluation from all areas, the documentation was reviewed and an implementation programme devised. The first stage of full implementation began in December 2013, after addressing issues such as the need for improved availability of the documentation, increased availability of support and guidance tools, and removal of old documentation. During implementation, the ongoing developmental needs of nursing staff were identified and addressed in each ward area. A new audit tool was developed, which, after testing in a paper version, was made available electronically to provide a means of monitoring progress. This tool consists of eight core questions with drop-down yes/no options used across all specialty areas in NHS Lanarkshire, and additional questions specific to each area (Box 2).
Progress to date Much progress has been made with the review and rationalisation of the documentation. For example, neonatal services has reviewed and updated more than half of its documents, and one-third of all other acute care services documents have been similarly updated. Children’s services has rationalised its community documentation, incorporating best practice such as Getting it Right for Every Child (The Scottish Government 2014), enabling a smooth transition to an electronic record. Nutrition and dietetic services have created a single set of generic documentation incorporating best practice,
which is now used by their staff in community, acute care, learning disabilities and mental health services. The NHS Lanarkshire LBC programme has provided financial support for graphic design expertise, resulting in approximately 200 documents being reproduced to reflect current best practice standards. The Clinical Documentation Review Group is in its fourth year of activity and is evolving into a strategic steering group. An NMAHP Clinical Documentation Policy Summary (NHS Lanarkshire 2014) was produced to highlight the guiding principles of the policy for clinical staff. Recent updates from the subgroups show that most are accurately maintaining a record of all documentation. There are approximately 1,000 documents registered through this system – a large number. However, by introducing this system and bringing the number of documents to light, we anticipate that there will be a rationalisation over time, which will be assisted by the arrival of electronic patient records. The Personal Care Record has been implemented in all three acute district general hospitals, and plans are being made to take it to the associated hospitals for the care of older patients and GP-led community hospitals. Future considerations include: Ongoing partnership work with programmes such as the Scottish Patient Safety Programme (HIS 2014) and the Person-Centred Health and Care Collaborative (2013) to ensure that contemporary evidence-based practice is reflected in documentation.
BOX 2 Record-keeping and documentation audit Core questions: 1. The notes are well organised and it is easy to find the information required? 2. There is evidence that documents are written in accordance with professional standards (date, time, legible, signed, print name, no blank lines, black ink and in chronological order)? 3. There is evidence that assessment has been carried out, and needs and priorities have been identified? 4. There is evidence that legal issues have been considered and appropriate action taken, for example informed consent, do not attempt cardiopulmonary resuscitation order, mental health issues, adults with incapacity (power of attorney, welfare guardianship)? 5. There is evidence that risk has been considered within appropriate timescales and there is a comprehensive plan for how any risks are managed? 6. There is evidence that the care and treatment plan includes needs and priorities identified through ongoing assessment? 7. There is evidence that a multidisciplinary team or agency review has been undertaken? 8. There is evidence of patient/carer involvement in the development and review of the care plan? Specific questions – acute care services: There is evidence that personal goals/outcomes and the five ‘Must Do with Me’ areas (Healthcare Improvement Scotland (HIS) 2014) are documented? There is evidence that the five ‘Must Do with Me’ areas (HIS 2014) have informed the delivery of care?
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Art & science leading better care series: 6 Engaging in developments towards electronic patient health records, the use of which is supported in the literature (Barthold 2009, Laitinen et al 2010, Prideaux 2011, Blair and Smith 2012). Development of a local electronic centralised documentation information site to enable staff to identify and obtain only current and appropriate documentation.
Conclusion Good practice in documentation for the delivery of safe, effective and person-centred care has been achieved by NHS Lanarkshire in part by capitalising on opportunities to support improvement such as that provided by the local LBC programme. Progress has also been enabled through support from senior staff, ongoing input from the Practice Development Centre, and joint
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Acknowledgement Nursing Standard would like to thank Dr Kathleen Duffy, NHS Education for Scotland nursing and midwifery practice educator, Practice Development Centre, NHS Lanarkshire, for developing and co-ordinating the Leading Better Care series of articles.
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Better documentation improves patient care Kent P, Morrow K (2014) Better documentation improves patient care. Nursing Standard. 29, 14, 44-51. Date of submission: June 26 2014; date of acceptance: August 8 2014.
Abstract This article is the sixth in a series of seven describing the journey within NHS Lanarkshire in partnership with the University of the West of Scotland to support nursing and midwifery leadership roles through Scotland’s Leading Better Care programme. Preceding articles have provided an overview of the programme and discussed a range of staff development work programmes. This article describes work carried out on clinical documentation to promote delivery of the three quality ambitions of safe, effective and person-centred care.
Authors Patricia Kent Practice development practitioner, documentation, Practice Development Centre, NHS Lanarkshire, Hamilton, Scotland. Karen Morrow Practice development practitioner, acute care, Practice Development Centre, NHS Lanarkshire, Hamilton, Scotland. Correspondence to: [email protected]
Keywords Documentation, Leading Better Care, nursing care, nursing standards, patient care, quality improvement, record-keeping
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: rcnpublishing.com/r/author-guidelines
THE NURSING AND MIDWIFERY Council (NMC) (2010) asserts that good record-keeping is: ‘An integral part of nursing and midwifery practice, and is essential to the provision of safe and effective care. It is not an optional extra to be fitted in if circumstances allow.’ Good record-keeping depends on good documentation, and this article presents a number of initiatives undertaken by NHS Lanarkshire to improve the documentation used by nurses, midwives and allied health professionals (NMAHPs). The process of improving documentation has supported the implementation of Leading Better Care (LBC), a national policy for NHS Scotland, previously described by McGuire and Ray (2014).
Documentation issues A common issue highlighted in internal complaints and incident reports in NHS Lanarkshire, and in external reports, reviews and investigations, is poor record-keeping and care documentation. A review of the literature shows that below-standard documentation and record-keeping issues are not only local to NHS Lanarkshire but are also replicated across health services nationally and internationally (Laitinen et al 2010, Lees 2010, Asamani et al 2014). The Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust January 2005-March 2009 (Francis 2010) identified issues with record-keeping including incomplete and inconsistent nursing records, and deficiencies in recording discussions with patients and family. The report recommended that a note-keeping review should be performed (Francis 2010). The Scottish Public Services Ombudsman (SPSO) (2013), in the annual complaints report for health, cited communication as a major issue in complaints regarding health services. Reasons for these complaints include: communication between health professionals; communication between health professionals and patients; and care documentation and record-keeping. In regard to
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record-keeping issues, the SPSO (2014) states: ‘Good record-keeping is not a nice-to-have, it is an essential component of good care and good complaints handling.’ Other issues identified in NHS Lanarkshire include inaccurate and inconsistent documentation; inefficiencies in the use of documentation; an absence of governance in documentation development, implementation and review; and duplication of effort for staff, patients and carers. International studies concur, with Barthold (2009) describing unnecessary duplication of care records and a lack of evidence-based documentation and documentation standards, and Paans et al (2010) reporting inaccurate nursing documentation in the Netherlands. Studies in Sweden, New Zealand and Australia have identified a lack of clarity and difficulty in describing patient care, treatment and progress (Törnvall and Wilhelmsson 2008, Tranter 2009, Blair and Smith 2012). One NHS trust in England identified that its four hospital sites each had different sets of documentation (O’Connor et al 2007). Researchers have also highlighted difficulties in relation to the multipurpose nature of clinical documentation – records must confirm the prescription of treatment and care, offer a narrative of care and changing patient condition, and confirm what has been done to prove that the plan of care is fulfilled (Frank-Stromborg et al 2001, Austin 2010, Prideaux 2011). The suggestion is that this may contribute to issues with record-keeping and documenting care.
Components of good documentation In addition to highlighting issues with documentation, the literature offers suggestions for improvement. Structured documentation, including the use of a nursing model, documentation system or headings is recommended (Björvell et al 2002, Kaakinen and Torppa 2009, Prideaux 2011). Participants in a study conducted by Björvell et al (2003) commented that structured documentation made nurses think more and in a different way about their patient care. Structured documentation is also seen as important for the successful transfer of information from paper to electronic patient record systems (Prideaux 2011, Wang et al 2011). Electronic patient record systems have been shown to reduce the time spent documenting care, thus allowing more time with the patient, improving the quality of documentation and allowing easier auditing of practice. However, this should take place only with a fully supported implementation process and appropriate
technology (Barthold 2009, Prideaux 2011, Blair and Smith 2012). A meta-analysis by Jefferies et al (2010) identified seven essential components of quality nursing documentation (Box 1). Factors such as access to education programmes, improved nurse-to-patient ratios and a positive staff attitude were identified by Paans et al (2011) as being potentially beneficial for nursing documentation. Müller-Staub et al (2007) reported significant improvement in documenting nursing diagnoses (identification of problems), interventions and outcomes following staff education. The benefits of training on how to write clear records and regular auditing have been described (Johnston et al 2010, Jefferies et al 2012). Frank-Stromborg et al (2001) cited adhering to documentation guidelines and principles as essential for improving the accuracy of records and increasing the likelihood of improved patient care.
Documentation initiatives in NHS Lanarkshire The documentation work in NHS Lanarkshire was supported by the local NMAHP Practice Development Centre and in particular by the establishment of a practice development practitioner post for documentation. The following areas of work were prioritised: A review and rationalisation programme for existing documentation. Development of an infrastructure to support documentation control, management and quality assurance. Implementation of sets of standardised documentation appropriate in different care contexts.
Documentation review and rationalisation
In 2009, a review and standardisation of nursing documentation for the district nursing service
BOX 1 Seven essential components of quality nursing documentation Nursing documentation should: 1. Be patient centred. 2. Contain the actual work of nurses, including patient education and psychosocial support. 3. Be written to reflect the objective clinical judgement of the nurse. 4. Be presented in a logical and sequential manner. 5. Be written contemporaneously (as events occur). 6. Record variances in care within and beyond the healthcare record. 7. Fulfil legal requirements. (Adapted from Jefferies et al 2010)
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Art & science leading better care series: 6 were undertaken as precursors to a move to an electronic patient record. The review revealed that many documents were no longer fit for purpose, and this provided the impetus for a major assessment of all inpatient and outpatient documentation, which was performed in 2010. Paper and electronic documents were gathered from more than 130 areas in three acute district general hospitals, 12 associated hospitals (including mental health, learning disabilities and care of older people specialties) and four GP-led community hospitals. This resulted in a compilation of approximately 2,500 documents and identification of issues including: Documentation not reflecting evidence-based practice from guidelines, for example the Scottish Intercollegiate Guidelines Network (SIGN) (2014), and improvement programmes such as the Scottish Patient Safety Programme (2014) and the Person-Centred Health and Care Collaborative (Healthcare Improvement Scotland (HIS) 2014). A lack of clarity about when documents were created or by whom. Variations of the same type of document in use, creating confusion and resulting in the duplication of effort for staff and patients. Poor quality and supply of documentation, for example some were photocopied to the point of being almost illegible. The initial decision was to focus on inpatient services within the acute hospitals and to prioritise the 30 most commonly used or ‘standard’ documents in these services. These documents included charts such as those used for vital signs and fluid balance; assessments such as falls risk, pressure ulcer risk and mobility; and forms such as those for surgical procedures and legal matters. As mentioned earlier, there were several versions of documents, and a review of 122 documents was required. The scale of this work meant that it took until the end of 2011 to finalise the 30 standardised and evidenced-based documents. This process provided the opportunity to remove out-of-date documents and the rationalise the use of an external printing company, which allowed cost savings in the longer term. As part of the standardisation process, a one-day event took place in September 2012 to review all remaining acute care services documentation. Nurse representatives from all acute services met to review and decide on the potential use of these documents. This resulted in the overall documentation list being reduced from 516 to 410. A second documentation rationalisation event was held in
July 2013, reducing the number of documents further to 261.
Infrastructure to support documentation control, management and quality assurance
The documentation review process identified the need for a sustainable approach. Sustainability in health care is defined as: ‘when new ways of working and improved outcomes become the norm’ (NHS Scotland Quality Improvement Hub 2014). To achieve this, an NHS Lanarkshire-wide NMAHP Clinical Documentation Review Group was set up in 2011 with two main objectives: 1. To identify and implement a single system of quality control and governance for the development, ratification, implementation and review of NMAHP clinical documentation. 2. To set standards and principles for the format and content of NMAHP clinical documentation that reflect professional standards, caring and compassionate practice, values and evidence-based practice. The Clinical Documentation Review Group identified and commissioned 15 subgroups in which six specialty areas and nine allied health professional (AHP) departments would take responsibility for documentation in their own areas. With later developments it has grown to eight areas and ten AHP departments. A structure outlining reporting mechanisms to the subgroups and other relevant local and national groups was agreed (Figure 1). The Clinical Documentation Review Group’s initial work concentrated on the development of a documentation policy to incorporate standards and principles. This policy was based on World Health Organization (2007) guidelines and was launched in June 2012. It describes the desired attributes for NMAHP clinical documentation as: Clear. Concise. Complete. Correct. Consecutive. Contemporary. Confidential. Person-centred. Collaborative. Comprehensive. These components are set out in three guiding principles for documentation: Guiding Principle 1 – comprehensive and complete record. Guiding Principle 2 – person-centred and collaborative.
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Guiding Principle 3 – ensuring and maintaining confidentiality. The policy describes the system of quality control and governance for the development, ratification, implementation, review and supply of all NMAHP clinical documentation.
Implementation of sets of standardised documentation within different care contexts
The NMAHP Clinical Documentation Review Group’s policy states that ‘where appropriate, documentation will be standardised across NHS Lanarkshire’ (NHS Lanarkshire 2012) to reduce variation in practice and reflect a consistent approach to care for patients. Variation, either by organising the same thing in different ways, or by performing different tests for the same
condition, results in service delays (NHS Institute for Innovation and Improvement 2013a). In 2010, a UK-wide scoping exercise was undertaken by the NHS Lanarkshire acute care subgroup of the Clinical Documentation Review Group to identify areas of good practice in relation to documentation – that is, documentation that promotes person-centred care, is structured and reflects the nursing care process. The Gloucestershire Patient Profile from Gloucestershire Hospitals NHS Foundation Trust (2010) was selected and permission obtained to adapt it for use in Lanarkshire. In June 2011 a Nursing Care Record was produced based on the Roper, Logan and
FIGURE 1 Clinical Documentation Review Group reporting structure NHSL Clinical Governance Committee Other disciplines/agencies: Medicine Pharmacy Local authorities Managed clinical networks
Local clinical quality and governance groups
Acute care subgroup
Addictions subgroup
NMAHP Senior Leaders Group
Leading Better Care/Best Possible Start boards
NMAHP Clinical Documentation Review Group
Children and young persons’ service subgroup
Long-term conditions subgroup
Mental health and learning disabilities subgroup
Midwifery subgroup
Other local groups: Scottish Patient Safety Programme Person-Centred Health and Care Collaborative Service improvement boards MiDIS* TrakCare*
Neonatal subgroup
Public health subgroup
AHP Professional Leads Group
AHP subgroups: Audiology Dietetics Occupational therapy Orthoptics Orthotics and prosthetics
Physiotherapy Podiatry Radiography Speech and language therapy Spiritual care services
*Electronic information systems AHP = allied health professional, NHSL = NHS Lanarkshire, NMAHP = nursing, midwifery and allied health professional
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Art & science leading better care series: 6 Tierney model of nursing (Roper et al 2000). This was produced in booklet format since consultation with staff had identified that having everything in one place would reduce the risk of documentation not being completed and staff having to spend time sourcing documents. Contents included: Reason for the patient’s admission and goals of care. A systematic structure to record assessment of activities of living, and care planning, implementation and evaluation. Record of intentional rounding – care rounds or comfort rounds, which take place regularly to check patients’ needs (National Nursing Research Unit 2012). Record of communication with relatives and carers. The activities of living assessment also incorporated trigger questions in relation to best practice on pressure ulcer risk assessment (HIS 2011), falls risk assessment (National Institute for Health and Care Excellence 2004), and the peripheral vascular catheter insertion and maintenance care bundles (HIS 2013). Documentation testing was performed in June and July 2011 using the plan, do, study, act (PDSA) cycle (NHS Institute for Innovation and Improvement 2013b). The documentation was reviewed and the finalised version implemented between March and May 2012 together with guidance for staff and provision for ongoing audit. In November 2012, an online survey on the Nursing Care Record was distributed to all senior charge nurses, AHP leads and other relevant staff, for example infection control and tissue viability nurses. Approximately 100 staff were invited to respond, and there was a 40% response rate. The survey consisted of five questions: 1. Which specialty do you currently work in? 2. Have you used the Nursing Care Record? 3. Is the Nursing Care Record effective in demonstrating the individualised care needs of your patients? 4. Are further improvements required to the Nursing Care Record? 5. Please detail any other recommendations you have to assist in the review of the Nursing Care Record. A total of 67% of those who responded agreed that the Nursing Care Record was effective in demonstrating the individualised care needs of patients. However, the same percentage also stated that further improvements were required. Specifically, it was suggested that
more training was required to improve the consistency of completion and the layout of the Nursing Care Record needed to be amended to increase ease of use. In addition to incorporating the survey results into a further revised version of the documentation, it was important to reflect the wider initiatives in NHS Scotland. Features of the revised version included: Reason for patient admission and person-centred goals of care, including the five ‘Must Do with Me’ areas (Person-Centred Health and Care Collaborative 2013). Activities of living assessment, incorporating latest best practice regarding peripheral vascular catheter insertion, maintenance care bundles, falls risk and pressure ulcer risk assessments (HIS 2013). Care planning, implementation and evaluation (a multidisciplinary notes section for all staff), in addition to a record of communication with relatives and carers. Commonly used charts and assessments, for example the Malnutrition Universal Screening Tool, a mobility assessment and the Abbreviated Mental Test. As part of these changes and following consultation with staff, the documentation was renamed the Personal Care Record, and a test version was produced in June 2013. To assist the introduction of the Personal Care Record, support and guidance for staff within the testing and implementation phases were provided. Implementation was led by a group of band 5 staff nurses who had dual roles within practice development and clinical practice. They were supported by the NMAHP Practice Development Centre within the local LBC programme. This approach enabled consistency, communication and developmental support for all 80-plus ward areas. Feedback from these nurses suggested that support given to ward staff was more effective when it included Practice Development Centre staff working clinically with nurses while using the documentation. PDSA cycle testing was again used during implementation of the new record system, with the first cycle beginning on three wards at each acute hospital site in June 2013. On each ward one person was identified to link with the Practice Development Centre team, with tailored support being provided, such as one-to-one conversations, presentations and compilation of sample documents demonstrating good practice in record-keeping. This process lasted for
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a three-week period and, following feedback and evaluation from all areas, the documentation was reviewed and an implementation programme devised. The first stage of full implementation began in December 2013, after addressing issues such as the need for improved availability of the documentation, increased availability of support and guidance tools, and removal of old documentation. During implementation, the ongoing developmental needs of nursing staff were identified and addressed in each ward area. A new audit tool was developed, which, after testing in a paper version, was made available electronically to provide a means of monitoring progress. This tool consists of eight core questions with drop-down yes/no options used across all specialty areas in NHS Lanarkshire, and additional questions specific to each area (Box 2).
Progress to date Much progress has been made with the review and rationalisation of the documentation. For example, neonatal services has reviewed and updated more than half of its documents, and one-third of all other acute care services documents have been similarly updated. Children’s services has rationalised its community documentation, incorporating best practice such as Getting it Right for Every Child (The Scottish Government 2014), enabling a smooth transition to an electronic record. Nutrition and dietetic services have created a single set of generic documentation incorporating best practice,
which is now used by their staff in community, acute care, learning disabilities and mental health services. The NHS Lanarkshire LBC programme has provided financial support for graphic design expertise, resulting in approximately 200 documents being reproduced to reflect current best practice standards. The Clinical Documentation Review Group is in its fourth year of activity and is evolving into a strategic steering group. An NMAHP Clinical Documentation Policy Summary (NHS Lanarkshire 2014) was produced to highlight the guiding principles of the policy for clinical staff. Recent updates from the subgroups show that most are accurately maintaining a record of all documentation. There are approximately 1,000 documents registered through this system – a large number. However, by introducing this system and bringing the number of documents to light, we anticipate that there will be a rationalisation over time, which will be assisted by the arrival of electronic patient records. The Personal Care Record has been implemented in all three acute district general hospitals, and plans are being made to take it to the associated hospitals for the care of older patients and GP-led community hospitals. Future considerations include: Ongoing partnership work with programmes such as the Scottish Patient Safety Programme (HIS 2014) and the Person-Centred Health and Care Collaborative (2013) to ensure that contemporary evidence-based practice is reflected in documentation.
BOX 2 Record-keeping and documentation audit Core questions: 1. The notes are well organised and it is easy to find the information required? 2. There is evidence that documents are written in accordance with professional standards (date, time, legible, signed, print name, no blank lines, black ink and in chronological order)? 3. There is evidence that assessment has been carried out, and needs and priorities have been identified? 4. There is evidence that legal issues have been considered and appropriate action taken, for example informed consent, do not attempt cardiopulmonary resuscitation order, mental health issues, adults with incapacity (power of attorney, welfare guardianship)? 5. There is evidence that risk has been considered within appropriate timescales and there is a comprehensive plan for how any risks are managed? 6. There is evidence that the care and treatment plan includes needs and priorities identified through ongoing assessment? 7. There is evidence that a multidisciplinary team or agency review has been undertaken? 8. There is evidence of patient/carer involvement in the development and review of the care plan? Specific questions – acute care services: There is evidence that personal goals/outcomes and the five ‘Must Do with Me’ areas (Healthcare Improvement Scotland (HIS) 2014) are documented? There is evidence that the five ‘Must Do with Me’ areas (HIS 2014) have informed the delivery of care?
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Art & science leading better care series: 6 Engaging in developments towards electronic patient health records, the use of which is supported in the literature (Barthold 2009, Laitinen et al 2010, Prideaux 2011, Blair and Smith 2012). Development of a local electronic centralised documentation information site to enable staff to identify and obtain only current and appropriate documentation.
Conclusion Good practice in documentation for the delivery of safe, effective and person-centred care has been achieved by NHS Lanarkshire in part by capitalising on opportunities to support improvement such as that provided by the local LBC programme. Progress has also been enabled through support from senior staff, ongoing input from the Practice Development Centre, and joint
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working with departments such as medical illustration and medical records and the many staff groups who have shown enthusiasm to improve their documentation and ultimately the care and treatment of patients. The change process inevitably raises questions regarding spread and sustainability, and there is local recognition that documentation management is an ongoing challenge NS
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Acknowledgement Nursing Standard would like to thank Dr Kathleen Duffy, NHS Education for Scotland nursing and midwifery practice educator, Practice Development Centre, NHS Lanarkshire, for developing and co-ordinating the Leading Better Care series of articles.
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