Patient records compliance audit
Health Boards should ensure that the nurse in charge of each ward audits compliance with the duty to keep clear and contemporaneous patient records.
How was this assessed?
Response
Accepted
Response
AcceptedSection 4.2 of the Scottish Government's response details professional standards for record-keeping, with the revised NMC code requiring nurses and midwives to maintain clear, accurate, and contemporaneous records. While the text does not explicitly state that the nurse in charge audits compliance, Section 3.3 notes that quality improvement uses a range of methods, such as audit, to deliver change that improves outcomes for people receiving services.
Published Evidence
Published assessments of implementation progress from inspectorates, select committees, official progress reports, and other sources. Check the source type badge to see whether each assessment is independent or government self-reported.
Excellence in Care CAIR Dashboard now monitors nursing care quality metrics including record-keeping standards across all NHS Scotland boards. Every board has an EiC Lead and a Digital Lead.
View detailed findings
CAIR Dashboard produced by Public Health Scotland provides standardised nursing and midwifery care quality metrics. Over 20 ratified measures with 30+ additional in development.