RECORD KEEPING PROCEDURE FOR COMMUNITY NURSING

RECORD KEEPING PROCEDURE FOR COMMUNITY NURSING First Issued Issue Version One Purpose of Issue/Description of Change Planned Review Date To promote safe and effective record keeping for all staff working in community nursing 2012 Named Responsible Officer:- Ratified by Date Service Improvement Team Nursing Policy Group May 2009 Policy File:- Nursing Policy File N o 63 Impact Assessment Screening Complete Date: April 2009 Full Impact Assessment Required Y/N UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM THE PCT WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION

CONTENTS PAGE CONTENTS PAGE Introduction 3 Aim 3 Target Group 3 Responsibilities of Staff 3 Examples of relevant documentation 3 Document control 4 Training 4 Related Policies 4 Caldicott Principles 5 Consent 5 Patients without capacity to consent 6 Best Interests consent form 4 6 Written consent forms 6 Information governance 6 Coordinating care with social services and other agencies 6 Patient Access and Request for Records 7 Copying letters to patients 7 Safe Storage of Records in Clinic Base and whilst Travelling 7 Archiving of Records 7 Additional notes for storing community nursing records 8 Supervision of Record Keeping Standards 8 A Z of additional information 9-13 Specialist Nursing Documentation 13-14 General Principles 14 Short Intervention Assessment Form 15 Base Documentation 15 Full Overview Assessment Documentation 16 Core Nursing Documentation 16 Care Plans 17 Additional Documentation 17 Missing Health Records 17 New Episode of Care 17 Specialist Nursing Teams 17 References 18 Consultation 18 2/18

INTRODUCTION NHS Wirral is committed to high standards of record keeping, to ensure safe, effective high quality nursing care for its service users. The Nursing and Midwifery Council (2007) states that: Record keeping is an integral part of nursing, midwifery and specialist public health nursing; it is a tool of professional practice and one that should help the care process. It is not separate from this process and it is not an optional extra to be fitted in if circumstances allow. AIM To outline the procedures for record keeping for all staff working in community nursing teams. To provide specific guidance relating to community nursing, this builds on existing PCT Health Records Policy and NHS Wirral Code of Conduct for handling personal and identifiable information. To inform existing and new community nursing staff with all detailed information relevant to Community Nursing and Specialist Nursing Teams. TARGET GROUP All staff working in community nursing teams including bank staff and nursing students will comply with this procedure. Record keeping standards will be audited yearly. RESPONSIBILITIES OF STAFF All staff working in Community Nursing are responsible for any health records; this responsibility is established and defined in law. As an employee, any records you create are public records and the principles of record keeping apply to all documentation. A full copy of the NHS Wirral Health Records Policy and NHS Wirral Code of Conduct for Handling Personal Information are both available on the NHS Wirral intranet site. EXAMPLES OF RELEVANT DOCUMENTATION Nursing records patient-held home and base notes Patient Medicines Administration Charts Faxes Memos Referrals Forms 3/18

Telephone message records All Diaries Accident / incident forms Clinic attendance sheets Blood Glucose Monitoring meter documentation Communication books Audio / video tapes Wound maps / photographs Electronic records DOCUMENT CONTROL Team leaders are responsible for ensuring their teams are using the most current versions of nursing documentation. It is important that old versions of forms referring to previous names of organisations are destroyed. TRAINING Every new member of staff attends an induction programme and Essential Learning within three months of coming into post and during local induction staff are provided with an overview of PCT Policies. All community nursing staff must attend Essential Learning every two years and team leaders/managers are responsible for ensuring that their staff attend mandatory training. RELATED POLICIES PCT Health Records Policy Mobile Phone Policy Health and Safety Policies Consent Policy Incident Reporting Policy Copying Letters to Patients Policy Code of Conduct for handling personal identifiable information Media Policy: Approval mechanisms for press releases Failure to Gain Access Policy Vulnerable Adults Policy Safeguarding Children Policy Pathway and Toolkit to the Mental Capacity assessment, under the mental capacity Act (2005) NMC (2008) Code of professional conduct: standards for conduct, performance and ethics Community Nursing Supervision Policy Non Medical Prescribing Procedure PCT Information Governance Policies NB Always use most current versions of PCT and NMC policies as may be superseded at any time 4/18

CALDICOTT PRINCIPLES refer to NHS Wirral Code of Conduct for issues relating to safeguarding personal and identifiable information. All NHS organisations have a designated Caldicott Guardian to oversee access to patient information. Dr Shanila Roohi, is the Caldicott Guardian for NHS Wirral Email: shanila.roohi@wirral.nhs.uk CONSENT see NHS Wirral consent policy for full details The Department of Health consent principles are fully outlined in the NHS Wirral Consent Policy. All registered nurses must promote a care environment that promotes informed and understood consent, privacy and dignity and actively involve the patient in their care planning. Valid Consent is a patient's agreement for a health professional to provide care. To demonstrate capacity individuals should be able to;- 1. Understand information about the decision to be made 2. Retain that information in their mind long enough to make a decision 3. Use or weigh that information as part of the decision making process 4. Communicate their decision ( e.g. by talking or sign language ) For consent to be valid, the patient must be able to:- Make a free choice Free from pressure Given voluntarily Evidence of valid consent must always be documented within the patient s records and should be noted each time care is provided. However, for ongoing, routine interventions e.g. administration of daily insulin, valid consent should be obtained and documented in the care plan prior to the initial intervention and should then be reviewed at regular intervals or if the patient s circumstances or treatment changes. Valid consent should be reviewed when care plans are updated. Reference guide to consent for examination or treatment provides a comprehensive summary of the current law on consent and 12 key points on consent. This one page document summaries those aspects of the law on consent, which arise on a daily basis. Copies available from:- http://www.dh.gov.uk/en/advancesearchresult/index.htm?searchterms=cons ent 5/18

PATIENTS WITHOUT CAPACITY TO CONSENT It should be noted that if an adult does not have the capacity to provide valid consent (either temporarily or permanently) then no other person can consent on their behalf this includes the patient s General Practitioner (GP). Please refer to NHS Wirral Mental Capacity Act Toolkit for further information http://nww.wirral.nhs.uk/about_services/services_that_the_pct_provides/com munity_nursing/mca/ BEST INTERESTS CONSENT FORM FOUR Health care can be given in the patients best interests. To establish best interests it is essential that the views of all persons involved in that patient s care are sought, this would include carers and relatives, GP and other relevant professionals or agencies. It may be necessary to seek advice from your Service Manager on a case by case basis or the Safeguarding Team. In some cases the Service Manager may need to consult with the PCT solicitors for specific legal advice. WRITTEN CONSENT FORMS The only written consent form at present in community nursing is for taking a photograph. It is rarely a legal requirement to obtain written consent in community nursing. It is essential if a procedure has significant risks which the patient needs to be aware of the risks e.g. types of surgery. See the PCT Consent Policy for further information. INFORMATION GOVERNANCE refer to Health Records Policy CO-ORDINATING CARE WITH SOCIAL SERVICES AND OTHER AGENCIES In some instances, particular agencies have a statutory obligation to assist each other or to work together. Essential information must therefore be able to pass between the NHS, local authority Social Services and other services contributing to a planned programme of care. If patients decline to give permission to share information, which impacts on the ability of staff to provide safe packages of care, contact your Service Manager for advice on a case by case basis. Adapted from Confidentiality: NHS Code of Practice (Department of Health 2003) (Available from www.dh.gov.uk 6/18

PATIENT ACCESS AND REQUEST FOR RECORDS Refer to Health Records Policy COPYING LETTERS TO PATIENTS Patients have an automatic right to receive copies of letters written about their care. See NHS Wirral: Copying Letters to Patients Policy, for specific guidance. SAFE STORAGE OF RECORDS IN CLINIC BASES AND WHILST TRAVELLING Staff must take all reasonable efforts to safeguard confidential client records and personal identifiable information, including the following measures: Patient identifiable information, including nursing records, Community Nursing Weekly Information Sheets, diaries etc. should not be left unattended in cars All efforts should be made to return nursing records either to base or patient/client home. In the event of working out of hours all staff should ensure that all patient/client information should not be left in their car overnight and kept secure in their own home out of view from family and friends. Records must be carried in a nursing bag at all times Patient identifiable information should not be left anywhere where it could be viewed by a member of the public Records must be stored in a secure room and filed appropriately when not in use Personal identifiable information should not be visible to the general public at reception areas No Information technology equipment can be used to store patient information unless it has been supplied and approved for safety by Wirral Health Information Systems (WHIS) and your Service Manager, using all recommended passwords and encrypted e.g. portable devices such as pen drives All employees with access to personal identifiable information have a duty to safeguard that information under the confidentiality code of conduct. Administration of patient related information must only be delegated to another team member if they are aware of their responsibilities under this code. 7/18

ARCHIVING RECORDS Records should be compiled and sent for storage in the following way: Request designated boxes from Community Nursing Office Discharge patient from caseload Patient s name, date of discharge / date of death should be marked clearly on the front of the record Segregate records alphabetically Label box by name of clinic, type of record and year of discharge Only fill box to ¾ full Contact Wirral University Teaching Hospital NHS Foundation Trust transport services to arrange collection. Also contact: PCT Archiving Officer to inform them that records have been sent Records of children should be clearly marked with the date of discharge/death and sent separately for storage N.B. Community Nurses with children s records:- Pre school Children on the child s discharge the record needs to be given to Health Visitor to be archived with Health Visiting Record School Age Children records to be put into a brown envelope marked Children s Records and inserted in the front of the archive box. Mark the archive box Also Contains Children s Records Records should be stored together and labelled with the name of the clinic base from which they originated: ADDITIONAL NOTES FOR STORING COMMUNITY NURSING RECORDS Community nursing patient records should not be removed from the blue cover on discharge Notes in red files should be removed from the file and plastic pockets if used and bound together in blue folder using treasury tags and stored in chronological order The date of discharge / date of death should be marked clearly on the Assessment Form in both the patient-held record and on the base notes The base notes should be filed in front of the patient held record and then secured in a blue folder Patient s name, date of discharge/death should be written clearly on the top right hand side of the blue folder using either permanent marker or adhesive label The record should then be boxed for long-term storage as described above Any problems with this system needs to be discussed with nurse managers and an incident form completed 8/18

SUPERVISION OF RECORD KEEPING STANDARDS It is the responsibility of every team leader/community matron or registered nurse who delegates care to non registered staff, to have a system in place to supervise the standards of record keeping within the team. There needs to be evidence that this has taken place e.g. as part of team meetings, one to one meetings, peer review, during management supervision or part of personal developmental reviews. During one to one management supervision, individual staff members should bring a set of health records that they have completed to the session for discussion with their team leader; to help maintain and improve record keeping standards. The Trust can provide support through training, policies and professional guidance from Nurse Management / Service Improvement Team in relation to record keeping. It is no defence, if held accountable, to your professional body or internal inquiry to say you are unaware of record keeping guidelines and legislation. A-Z OF ADDITIONAL INFORMATION Bank nurse work sheets Any work delegated to bank nurses must be documented on the designated bank nurse work sheet. The bank nurse should complete the comments section for each patient if appropriate and sign off duty in the space provided. These sheets should then be stored alphabetically by the nurses surname at base for future reference, and retained for three years Bed Rail Risk Assessments/Bed Rail Fitting From 1 st June 2007 bed rail assessments/bed rail fitting can only be carried out by a nominated bed rail assessor following training and assessment of competency by a member of the Service Improvement Unit. The risk assessment and documentation must be completed prior to the equipment being ordered. Assessment documentation is to be kept in the patient s home record, filed after the manual handling risk assessment. Blood Glucose Monitoring Meter Documentation Ensure that each book has the serial number of the meter written inside the quality control book. The books need to be stored at base. Under the Consumer Protection Act, these records must be kept for 11 years. Communication Books Must be stored at base in a secure room and kept for a period of three years. After this time they must be shredded as they may contain patient identifiable information. Each member of the team, including bank staff and relief team staff must understand the importance of using this form of communication and where it is kept. 9/18

Community Equipment All orders for community equipment a standard stock order form should be completed and faxed to the community equipment service. A copy of the original request filed in the base notes. Any advice given on use, care and maintenance of equipment must be documented in the patient s health records. Community nursing care for children under the age of 16 years On arranging the first home visit, ascertain whether the child s parent / guardian will be present. No nurse should be visiting children under the age of 14 years if the parent/appropriate guardian is not present. Fraser Competence can be sought from older children e.g. 15 18 year olds and documented in their health records. Permission must still be sought from the parent if they are not to be present at the visit to confirm they can access the family home, document discussion in the health records. Nurses working with children and young people should be confident and competent in providing the fundamental aspects of care (Nursing and Midwifery Council NMC 2008). Any procedure that you are requested to undertake for children and young adults that you are not competent to carry out; please discuss with the referring clinician and inform your locality nurse manager, as soon as you receive the referral. Community Patients Medicines Administration Chart The (blue) Community Medicines Administration Chart is to be completed by the prescriber for all prescribed medications to be administered by a member of a Community Nursing Team. Medicines administration charts are valid for 6 months and will require updating after that date. A new chart will be required at each new episode of care; if a medication is to be added, changed or following a new admission a new chart must be written and the previous chart discontinued. Prescriptions for controlled drugs have a shorter expiry date, and should be updated every 28 days. Ref: Standard Operating Procedure for Medicine Administration in Community Nursing Please contact Service Improvement Team for further information if required Nursing / Residential Homes Medication administered to patients in nursing and/or residential homes must be recorded in the patients medicines administration record (MAR) as well as NHS Wirral documentation to reduce risk of medication error. Data Information Sheets (Community Nursing Weekly Information sheet) These sheets should be completed weekly and faxed to 0151 653 8272. These should be stored at your base for one year from the date of completion. At the end of this time, the sheets should be shredded or disposed of in confidential waste bag. 10/18

Disposal of prescribe controlled drugs form refer to Standing Operating Procedure for destruction of patients controlled drugs in the community Immunisations comply with the relevant Patient Group Directive (PGD) A PGD is a specific instruction for the supply and administration of a named medicine to a group of patients in an identified clinical situation. It is the Team leader s responsibility to ensure each eligible staff members receive a personal copy of each PGD. A personal copy of the PGD should be retained by staff members and the nurse must take their copy of the PGD when visiting patients. Before medication can be administered the PGD must have been read and signed and the guidance within the direction must be followed. Nurses must attend mandatory updates every two years Administration must be recorded on GP records due to the risk of the vaccine being given twice or not at all. Arrangements should be made with individual practices as to how this should be achieved. The Community Nursing Team member should not be responsible for entering this information onto the practice computer system. Liverpool Care of the Dying Pathway for the Dying Phase Once a patient has died the LCP should be stored at the front of the nursing documentation for auditing purposes and retained in base for 12 months. The records of patients who had an LCP need to be stored separately in the file, for ease of access when auditing the records. Patients health records (with an LCP) need to be filed chronologically by date of death. The LCP Post Pathway Analysis form must be completed following the death of a patient to monitor the outcome and/or variances of the delivery of palliative care services. The task of completing the post pathway analysis form can be delegated to another member of the team to transcribe the details from the Liverpool Care Pathway. Please return to Audit Support, Service Improvement Unit For further guidance please refer to Clinical Protocol for Liverpool Care of the Dying Pathway on the PCT intranet site. Inter-Agency Referrals Copies of any referral made, including via the telephone, must be documented and secured within the base notes. Telephone referrals should be followed up by completing the appropriate inter-agency referral form within the same working day if possible Mobile Phone Work or personal mobile phone numbers must not be given to patients under any circumstances. If using a mobile to contact patients, ensure you have blocked your number which will withhold your number from the patients 11/18

phone. Mobiles must not be used to text patients. Contact your manager for advice on how to block your phone. Non Medical Prescribing - Record Keeping Refer to the Non Medical Prescribing Policy Safeguarding of children and vulnerable adults Seek immediate advice from PCT Safeguarding Service Team If you have any suspicions that a child is being abused or a vulnerable adult is being mistreated discuss with your line manager and refer to relevant NHS Wirral Policies. Record of Patient Care in Clinics / GP Surgeries Nursing care provided in GP surgeries is to be recorded onto the GP records or the GP computer system. Recording health care on a computer should adopt the same standards of practice as hand written records. Therefore, any entry needs to be clearly identifiable and evidence patient consent. If the patient is seen both in the home and at the surgery, a full care plan using NHS Wirral documentation should be used. Risk Assessments There are some specific risk assessments available on the NHS Wirral intranet. Refer to the PCT intranet as this list is not exhaustive. Risk assessments are to be carried out on all homes, with particular attention where animals are present. Service users are to be requested to secure animals away from any area where staff members may be prior to staff visiting. Staff are not to engage in contact with animals and staff must report incidents involving animals. It is a COSHH requirement that a risk assessment must be carried out for all patients receiving oxygen therapy, both long and short term oxygen. See risk assessment available on the NHS Wirral intranet. Patients who are being considered for advanced preparation of insulin need a risk assessment to be completed, including patients / carers ability to self administer insulin and the risk to staff of needle stick injury. Advanced preparation of insulin can only be drawn up for twenty-four hours and syringes must be labelled individually (NMC 2008). Refer to Standing Operating Procedure for advanced preparation of insulin. Taking the patient health records out of the home If the patient s home health records are taken out of the home, the records must be returned within 24 hours to maintain safe continuity of health care. Telephone Calls All patient related telephone contact, including health advice, must be evidenced in the patient s record. Messages should be documented on a 12/18

carbonated message book and the top copy of the message filed in the patient s base notes. Any health related advice or patient related discussions should be documented in the base notes on the communication sheet. The patient s health record should also be updated if any aspect of care is affected as the result of a telephone conversation. Message books need to be kept for three years and then shredded or disposed of in confidential waste bag. Messages taken by other members of the team need to be signed, dated and timed when read as an acknowledgement the message has been seen before being filed. Visiting Times Appointment times are not given for non-timed treatments. However, it is courtesy to provide an estimation of time such as morning or afternoon. Also, wherever possible, the patient should be informed if any delay is expected Work Diaries Diaries should be stored at your base when completed at the end of the year and kept for a period of three years. After this period the diaries should be shredded or placed in a confidential waste bag as they contain patient identifiable information. Entries must be recorded in black ink, do not use pencil or highlighter pens. Bank staff must not use diaries bank staff must only use bank diary sheets Do not record any patient clinical information in your diary as it forms part of a patient s record SPECIALIST NURSING DOCUMENTATION Please use specialist documentation when required and refer to specific policies and procedures for guidance Continence Assessment Community nurses only carry out continence assessments for adults who are palliative/terminal patients or for patients who are incontinent of faeces. For patients who are experiencing both urine and faecal incontinence and patients who are incontinent of urine only refer to Specialist Continence Service Continence Clinics: Level 1 and Level 2 Clinics Treatment at these clinics will be documented using the Integrated Care Pathways devised in partnership with Wirral Hospitals Trust. Continuing Health Care All patients who have had a comprehensive nursing assessment, the continuing health care needs check list must be completed. If you are unsure if the patient can apply for continuing health care then the decision to support tool can be completed. 13/18

Ear Care Documentation The ear care assessment documentation (see Ear Care Policy in the Nursing Policy file) must be completed and filed in the base notes. Leg Ulcer Assessment Forms - are available on the PCT Intranet Leg Ulcer Clinics Treatment at these sessions should be recorded on the leg ulcer Assessment documentation. Pain Assessment Charts - available on the Intranet under assessment charts Pressure Ulcer Assessment Documentation All patients who are assessed as at risk require pressure redistributing equipment (mattresses; replacements or overlays) must be assessed using the pressure ulcer risk documentation. Subsequent evaluation should occur 3 monthly or depending on clinical need. (NICE Guidelines 2005). Pressure ulcer documentation must also be used for assessing patients with pressure ulcers. All pressure ulcers grade 2 and above must be reported using a PCT Incident Form (NICE Guidelines 2005). Wound Mapping reassess every 4 weeks as a minimum This must be recorded on the wound care plan and filed behind the relevant care plan associated with that particular problem. Wounds should be measured using either a disposable tape measure or photographed, any photographs taken must not be stored on a computer but printed off and stored in both the patient s home and base records. Written consent is required when photographing wounds see consent form for clinical photography. This provides a baseline measurement from which to evaluate wound-healing progress. Wounds should be reassessed every four weeks as a minimum (often more frequently depending on clinical judgement) and frequency of reassessment should be recorded on the wound care plan. For specialist advice regarding wounds and pressure ulcers contact Tissue Viability Specialist Nurses. GENERAL PRINCIPLES - Follow NHS Wirral Record Keeping policies Each sheet included within a patient s plan of care must be clearly labelled with the patient s full name, date of birth and National Health Service Number Each sheet should be secured within an appropriate folder (blue folder or red ring-binder) Every entry in the patient s record must have the date (day, month, year) and time (24 hour clock) of the intervention recorded All staff involved in the patient/clients care must print, sign their name and record their designation. 14/18

The practitioner s printed name, signature and designation must be recorded on every entry made If the date and time of an event / intervention differs from when the records are written up, this must be clearly noted under the signature Any reports / results / letters or other incoming documentation relating to patient care, practitioners must print name, signature, designation and dated by the practitioner before filing to acknowledge that they have received and read the referral, results etc All verbal communication relating to a patient s care following referral must Be documented on the communication sheet for base records and not on The referral form, this then would form part of the base record. SHORT INTERVENTION ASSESSMENT FORM Short documentation was launched across NHS Wirral from 2 nd January 2009 and designed to be used for self-caring patients who require short interventions and will be on the community nursing caseload less than four weeks. There is a national requirement to offer a more in depth assessment framework for those with greater health needs, refer to Wirral Adult Common Assessment Tool. Once the assessment has been completed the form up to and including the care plan will need to be photocopied for base notes. If patient care exceeds one month of treatment then a contact and overview assessment will need to be completed. Short documentation can be ordered on line: Code number WAA 837. Do not photocopy documents except for base notes. Short intervention Continuation sheet: Code number WAA 838 Labels are available for on line ordering and contact information will be populated by the administrative support team at bases. Code Number WZO 126 Documents will be hole punched and contained in blue folder when in use When storing records, records are to be treasury tagged and bound in blue folder with base notes stored at the front. All forms need to have patient s full name, date of birth and NHS number. Risk assessments in relation to lone worker policy will still need to be completed (If patient requires additional risk assessments then consider the need for contact and overview) If patient has more than one goal they are to be numbered and detailed on the same page, any additional evaluation sheets can be added BASE DOCUMENTATION 15/18

To consist of: A photocopy of either the Wirral Common Assessment Contact Tool or the short documentation Referral Form Risk Assessment Form HS 9 (1&2) Communication Sheet Index of Care Plans FULL OVERVIEW ASSESSMENT - FILED IN RED RING BINDER Contents Page Wirral Adult Common Assessment Tool - Contact Document Wirral Adult Common Assessment Tool - Overview Document. This document needs to be reviewed every 6 months or when there is a change of circumstance. All other documentation e.g. referrals, faxes, letters, messages etc to be filed in chronological order in base notes. All documentation should be attached together using treasury tags, kept secured in a lockable cabinet or room. CORE NURSING DOCUMENTATION Community nursing leaflet Out of Hours Contact Numbers Communication Sheet Waterlow Score- to be reviewed every 6 months or when there is a change of circumstance, by completing new assessment documentation Relevant medication charts and forms A manual handling risk assessment form must be completed were a manual handling need has been identified. The documentation should be updated when the patient is reassessed. If no manual handling risk has been identified this also needs documenting on the risk assessment form. Patient Handling Risk Assessment (from Health and Safety Policy 4) forms (1) and (2) Specific Patient Handling Action Both to be reviewed every six months or when there is a change of circumstance, by completing new assessment documentation Index of care plans Nursing Care Plan-one plan for each problem Evaluation Sheet-all problems to be evaluated on the same sheet Medication administration chart Attendance Diary 16/18

If the patient is over 25 stone(158kg) then please refer to the Manual Handling Policy for Extremely Heavy patients, where necessary complete forms (1) and (2) from Health and Safety Policy 5 and seek advice from manual handling advisor. CARE PLANS Care plans can either be hand written or pre-prepared on a computer, printed and then signed by the practitioner. All care plans must be individualised, with evidence of patient and/or carer involvement and valid consent. No patient related data on care plans can be stored electronically without the explicit permission of the Service Manager and fully password protected by Wirral Health Informatics Services. The Service Improvement Team need to quality assure any generic care plans used in nursing. ADDITIONAL DOCUMENTATION A range of documentation had been developed for community nursing teams. These will be listed separately on the PCT intranet site, as they are frequently updated and revised. MISSING HEALTH RECORDS Any health records that go missing or are mislaid then staff need to inform their locality nurse manager and complete a PCT incident form. Nurses must complete a new set of health records for the patient NEW EPISODES OF CARE Only the previous assessment documentation can be used, patient details must be checked, new contact document completed if necessary. Relevant re-assessment documentation must be completed for the overview document. New specialist documentation must be completed. SPECIALIST NURSING TEAMS Community Matrons, Wirral Admission Prevention Service, Specialist Palliative Care Team, Parkinson s Nurses, Tissue Viability Nurses Specialist tools used by these teams to support the care planning process are to be inserted behind the relevant care plan. All nursing teams are to use the core nursing documentation. Note: Any care plan must be contemporaneous to provide a baseline record by which improvement or deterioration of patient's health can be assessed CLINICAL INCIDENTS 17/18

Any incidents relating to record keeping must be reported following the PCT incident reporting policy REFERENCES Department of Health (2003) Confidentiality: NHS Code of Practice www.doh.gov.uk/ipu/confiden Department of Health (2004) Choosing health Making Healthy Choices Easier. www.dh.gov.uk/en/publications andstatistics/publications/publicationspolicyand Guidance/DH_4094550 Department of Health (1997) 'Report on the Review of Patient- Identifiable Information www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyan dguidance/dh_4068403 Data Protection Act (1998) www.opsi.gov.uk/acts/acts1998.ukpga_19980029_en_1 Standards of Better Health (2004) Department of Health www.dh.gov.uk NHS Modernisation Agency (2003) Essence of Care - Patient Focused Benchmarks for Clinical Governance www.institute.nhs.uk National Institute of Clinical Excellence (2005) Guidance on Pressure Ulcer Risk Management and Prevention. www.nice.org.uk Nursing and Midwifery Council (2007): Guidelines for Record keeping www.nmc-uk.org Nursing and Midwifery Council (2008) Advice for nurses working with children and young people. www.nmc-uk.org Mental Capacity Act Tool Kit (2005) www.dh.gov.uk CONSULTATION Nursing policy group Nurse Managers 18/18