Stool records for CDI patients
Health Boards should ensure that where a patient has, or is suspected of having, C.difficile diarrhoea a proper record of the patient's stools is kept.
- 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 a proper stool record is kept for patients with suspected CDI 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 outlines the professional standards for record-keeping for nurses. The revised NMC code requires nurses and midwives to complete all records accurately and without any falsification, and to identify any risks or problems and the steps taken to deal with them. This ensures that a proper record of a patient's stools is kept when C. difficile diarrhoea is present or suspected.
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.
NIPCM includes specific guidance on CDI patient management including stool monitoring. Excellence in Care framework monitors fundamentals of care documentation standards.
View detailed findings
National guidance on CDI management is comprehensive. Ward-level compliance monitored through CAIR Dashboard and HEI inspections.