Care planning system
Health Boards should ensure that there is an agreed system of care planning in use in every ward with the appropriate documentation available to nursing staff.
- 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 an agreed system of care planning with documentation is in use in every ward 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 and accurate records. This includes identifying any risks or problems and the steps taken to deal with them, which supports effective care planning and ensures appropriate documentation is available to nursing staff.
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.
Excellence in Care framework directly addresses care planning systems. CAIR Dashboard monitors fundamentals of care including care planning documentation across all boards.
View detailed findings
EiC was commissioned specifically in response to the Vale of Leven Inquiry. Four essential requirements identified by families form the framework foundation.