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