Paul Bowie
Introduction The record-keeping practices of community nurses is an important clinical governance issue. Good quality record keeping helps to promote high standards of clinical care, enhance patient safety and minimise healthcare risk. In Scotland, NHS trusts must provide verifiable evidence that patients’ records are regularly audited to comply with NHS Quality Improvement Scotland Generic Standards (NHS QIS). The main aim of this study was to monitor compliance with the Nursing an MidwiferyCouncil’s(NMC’s)guidance on record keeping in order to fully satisfy the relevant NHS QIS generic standard for community nursing in our trust. A further aim was to simultaneously develop and test a peer review method of audit,which could be applied by nurses across the organisation.Design Criterion-based audit involving retrospective case note review by a neutral nursing peer.Setting Sixteen local health care co-operatives (LHCCs) in Greater Glasgow Primary Care Trust.Participants Caseload-holding health visitors and district nurses in each LHCC.Sample size A convenience sample of five records was randomly selected for each caseload holder.Results 271 community nurse practitioners audited 1239 records during the first audit data collection, with 366 reviewing 1835 records for the repeat audit. The initial audit findings were disseminated across the organisation and a number of recordkeeping practices were identified for improvement. Change interventions were agreed and implemented by local nurse practitioners under the guidance and leadership of senior nursing staff atLHCC level. The second audit data collection demonstrated that record-keeping practices had improved considerably, for example in the increased recording of next of kin details (P < 0.001), the reduced use of jargon or abbreviations (P 0.001), greater documentary evidence of nursing assessment (P 0.001), care planning (P 0.001) and decision makig (P 0.01), and the recording of review date for patients (P 0.001).Conclusions Overall compliance with the NMC guidelines has been improved and the requirement to comply with the NHS QIS generic standard satisfied. By adopting a planned and rigorous approach to peer review audit we have demonstrated that an important clinical governance issue can be monitored and improved with the effective use of existing organisational structures and strong professional leadership.
