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.
- The Scottish Government's response detailed professional standards for record-keeping, with the revised NMC Code (effective March 2015) requiring nurses and midwives to maintain clear, accurate, and contemporaneous patient records.
- The requirement that the nurse in charge audits compliance with record-keeping duties is embedded in the NMC Code's standards on record-keeping, which apply to all registered nurses and midwives practising in Scotland. The GMC's Good Medical Practice sets equivalent standards for doctors.
- The Health and Social Care Standards (published June 2017) include Standard 3: 'I have confidence in the people who support and care for me,' which encompasses professional standards including accurate record-keeping (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- Healthcare Improvement Scotland assesses record-keeping quality as part of its inspection programme, and the Scottish Patient Safety Programme promotes standardised documentation practices including safety briefs and structured handovers.
How was this evidence gathered?
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 progress from inspectorates, select committees, official progress reports, and other sources. Source type badge indicates whether each assessment is independent or government self-reported.
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