Transformation Directorate

Why we’re developing standards for nursing documentation

Helen Balsdon is a Florence Nightingale Foundation Digital Leadership Fellow and works in Digital Nursing at NHSX. In her blog post, Helen shares an update on the work taking place to develop a nursing documentation standard.

Our vision is to create a standardised framework for nursing documentation across England

This is important for a few different reasons.

As registered nurses, documenting the care we give is a core part of what we do and takes up much of our time. Indeed, Safer Nursing Care Tool data from 2016 suggested that we spend as much as 15% of our time documenting care and 10% of our time looking for information. That is 25% of the working day so we need to make sure that what we document is meaningful, and that we use technology to help us work smarter as a nursing team.

Our ambition is to define what documentation is required and when, then build on this using technology, to share information across organisational boundaries and care settings. We want to make sure that nurses caring for patients have the information they need at their fingertips, in a way that they understand, regardless of setting - whether that is hospital, home or care home.

The information we anticipate including in the core nursing documentation framework includes assessment of a person’s functional needs, such as nutrition, skin integrity, mobility needs, wound management plan. Additionally, we anticipate including key information that can help us make transitions of care between hospital, home and care home safer and seamless for our patients and their carers.

Our ambition places the patient at the centre of care. The key clinical objective is to enable the right information to be accessible to the right person at the right time, to make it easy for nurses and other healthcare professionals to make informed decisions and deliver timely and safe care.

This work also seeks to reduce unwarranted variation across the profession, and collectively work smarter to get the right care to the person in front of us quicker and in a way that improves their experience of care.

So, how are we going to do this?

From the work we have done so far, in partnership with the Professional Record Standards Body (PRSB), and from the many conversations we have had with nurses, we know that there is strong support for this work but also recognition that this could be fraught with complexity and it must be done well if it is to add value. We are drawing on this insight as we embark on the next phase of this work to define the content of the documentation framework.

This will again be done in partnership with the PRSB, who are the true experts when it comes to clinical records standards. The work will involve a number of different components that will help us understand national requirements, what nurses currently document, which tools they use to assess their patients, and the coding that underpins it all.

Once the content of this work has been agreed by our senior nurses across England, it will be shared widely so that organisations can start putting their implementation plans in place. We will then start the process of digitising this so that the information captured in electronic patient records can be shared across and between organisational boundaries and care settings.

We know that this work will not be without its challenges, but there are many opportunities too

We are hoping the framework will be useful across a range of care settings, which would mean the volume of organisations which could be supported is vast. We will use the collective voice of nursing to help us implement this documentation standard where it is relevant.

We also recognise that not all organisations are digital, or able to share information digitally. This is why we want to share the framework so that even if organisations work on paper they can still use this standardised approach to nursing documentation as standardisation is the first step in the process of going digital.

Alongside these big challenges, this work also offers many opportunities to improve patient safety and experience by working together and sharing information so that it follows the person receiving care.

It should also improve our experience of work if all nursing teams use the standardised documentation framework. This will make new roles more straightforward as we don't need to learn a new set of documentation but also, we hope, it will reduce the burden of documentation by working together as a nursing collective, Team CNO.

I am really excited about this work as I can see the potential to help us work more effectively together, regardless of where we work. In care settings we routinely use each other's documentation to continue care. Imagine the potential to do this across traditional organisational boundaries and care settings.

This is the true magic that digital offers us….so, let the magic begin!

Watch this space for an update in the new year to find out how this work is progressing!