Clinical Records

Recommendations related to clinical records

4

Recommendations

100% accepted

Government Response

Accepted (4)

Recommendations in This Theme

recommendation across 1 inquiry

Across 1 inquiry

Hyponatraemia Inquiry

Tagged Recommendations

4 total

IHRD-17 Accepted

Hyponatraemia Inquiry

Recording Changes in Accountability

Any change in clinical accountability should be recorded in the notes.

- HSC Trusts reported that nurse-to-patient ratios on paediatric wards have been reviewed in line with professional standards (IHRD Implementation Programme, Department of Health NI, …

IHRD-23 Accepted

Hyponatraemia Inquiry

Care Plan Availability at Bedside

The care plan should be available at the bed and the reasons for any change in treatment should be recorded.

- HSC Trusts reported that arrangements for parent and carer involvement in clinical decision-making have been formalised (IHRD Implementation Programme, Department of Health NI, March …

IHRD-26 Accepted

Hyponatraemia Inquiry

Recording Clinical Discussions

Clinical notes should always record discussions between clinicians and parents relating to patient care and between clinicians at handover or in respect of a change in care.

- HSC Trusts reported that clinical audit programmes for paediatric care have been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - No …

IHRD-29 Accepted

Hyponatraemia Inquiry

Record Keeping Audit

Record keeping should be subject to rigorous, routine and regular audit.

- HSC Trusts reported that arrangements for transfer of children between hospitals have been formalised with standardised protocols (IHRD Implementation Programme, Department of Health NI, …