NHS England (NHSE) has launched steering on clear and correct report protecting for nurses, with a concentrate on digitising documentation.
Good documentation is important to supporting skilled choice making and care in nursing and because the NHS more and more strikes to a digital-first method, it’s essential that the problem of shifting from conventional paper-based methods to digital ones is addressed.
In 2020, the digital nursing workforce at what was then NHSX labored with the Skilled Information Requirements Physique (PRSB) to have a look at the feasibility of creating a nationwide nursing documentation normal. The report’s advice was that the “normal must be interoperable and absolutely built-in into shared care data the place the provenance and contextualisation of affected person/citizen info is paramount for medical security”.
Now, NHSE has revealed a unified imaginative and prescient for producing good documentation with a standardised framework for nursing throughout well being and social care methods in England, which ensures nursing follow is supported by digital know-how.
The guidance – which was launched final week – will assist set the course for standardising nursing documentation; cut back unwarranted variation in what’s documented throughout organisations; proactively handle documentation; and assist using know-how as a way to streamline the method and assist efficient choice making.
NHSE additionally units out some primary ideas for digital instruments. This consists of that they need to facilitate intuitive information entry; assist the flexibility for information to be entered as soon as and reused the place clinically applicable and secure, as a way to keep away from repeat information entry; and assist looking out of the report.
As well as, it advises that medical choice assist instruments must be used to assist secure and efficient choice making and to streamline documentation on the level of care.
NHSE additionally underlines how the digitisation of documentation by nurses can even assist wider targets of extracting information. It notes that any digital system ought to visualise information in a approach that permits registrants to see developments over a time period. Moreover, it recommends instruments that assist information extraction from the care report and using enterprise intelligence instruments to assist reporting, service analysis, auditing and analysis. This is able to imply that no additional medical documentation would should be accomplished to assist audits or service analysis.
Digital Well being Rewired24’s convention programme will embrace a digital nursing stage, when it occurs at The NEC in Birmingham on the 12-13 March, the place the challenges going through nurses in a digital NHS shall be mentioned.