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.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

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.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

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.

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..

IHRD-29 Accepted

Hyponatraemia Inquiry

Record Keeping Audit

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

Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates..