Background It was identified that the hospice in- patient unit records were not as robust as they could be. Despite the patients receiving an excellent level of holistic care, this was not always evidenced clearly in the documentation.
Aim and Implementation To modify existing documentation to clearly evidence the excellent care being received by our in-patients and families, whilst being patient- centred and personalised. The time frame was set for compliance to be complete by the end of January 2017. Weekly audit to ensure the new documentation is fit for purpose and to identify any areas which need further development. Following the guidelines of the NMC code for nurses and midwives specifically sections: 10 – Keep clear and accurate records relevant to your practice … 3 – Make sure that people’s physical, social and psychological needs are assessed and responded to.
Outcomes Success to date has been extremely positive with outcome measures exceeding expectation across all areas.
Application into Hospice Practice An action plan was developed and implementation commenced of the recommended actions. The new documentation was rolled out on the 30 November and is now being used for all patients who are admitted to the in-patient unit. Care plans were redesigned to encourage planning and documentation of personalised care. Records audit was then done every week, all patients records are audited without exception.
Feedback from issues found through audit is given directly to the staff member involved as soon as possible either face to face or by email and clinical supervision documentation is completed for evidence of feedback. Compliance of feedback is checked the following week whilst doing the weekly audit. The nurse co-ordinators’ role defined to include monitoring of documentation following admission to ensure compliance sustaining improvements. There remained a need to continue weekly audits until staff have adapted and familiarised themselves with the documentation, by March 2017 following evidence of sustained compliance to the audit requirements, the audit was conducted fortnightly for three months and if remains stable will then be downscaled to monthly. Documentation is clearer and evidences patient and family engagement and consent in personalised care planning. Documentation compliance has improved.
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