R19 Response Accepted AI-assessed

ICN instructions recorded

Recommendation

Health Boards should ensure that where Infection Control Nurses provide instructions on the management of patients those instructions are recorded in patient notes.

Published Evidence Summary
The following publicly available evidence relates to this recommendation:
According to professional standards for record-keeping for nurses and doctors, NHS Health Boards are guided to ensure that instructions from Infection Control Nurses (ICN) on patient management are recorded in patient notes. According to the Excellence in Care (EiC) framework, nursing documentation standards, including the recording of ICN instructions, are monitored, and the CAIR Dashboard tracks care documentation compliance across all boards. According to Healthcare Improvement Scotland in January 2025, board-level compliance with these specific documentation standards varies.
How was this assessed?
Assessed by gemini-2.5-flash on 19 Mar 2026
Checked data held on this site (government responses, progress updates, independent evidence)
External sources searched: www.gov.uk, www.gov.scot, www.legislation.gov.uk, hansard.parliament.uk
This recommendation requires implementation across many organisations. The assessment reflects central policy response, not adoption in individual organisations.
Jurisdiction
Scotland
Response
Accepted
Accepted Scottish Government
18 Jun 2015

Section 4.2 of the Scottish Government's response details the professional standards for record-keeping for nurses and doctors. The revised NMC code requires nurses and midwives to complete all records at the time or as soon as possible after an event, identifying any risks or problems and the steps taken to deal with them. Similarly, the GMC requires doctors to record concerns and details of any action taken, ensuring that instructions from Infection Control Nurses are documented in patient notes.

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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.

Good Progress
01 Jan 2025
Healthcare Improvement Scotland Other

Excellence in Care framework monitors nursing documentation standards including recording of ICN instructions. CAIR Dashboard tracks care documentation compliance across all boards.

View detailed findings

National frameworks address this requirement but board-level compliance with specific documentation standards varies.

Excellence in Care CAIR Dashboard View Source
Source
Inquiry Vale of Leven Inquiry
Report The Vale of Leven Hospital Inquiry Report 24 Nov 2014
View Source
Responsible Bodies
NHS Health Boards (Scotland) Primary
Themes & Tags
Inaccurate and inaccessible patient records Poor health and social care integration Infection Control Records Nursing
Recommendation age 11.3 yrs
Last formal update 3932 days ago