About

It is vital that nursing and midwifery practice is supported by good documentation that supports professional decision making and care.

Why is it important?

Good documentation is an integral component of registrants’ professionalism and demonstrates evidence-based decision making and care.

The Nursing and Midwifery Council (NMC) Code (2018) requires nurses and midwives to keep clear and accurate records relevant to their practice. The code sets out the requirement for contemporaneous, accurate and factual record keeping, that is devoid of jargon.

For NMC registrants, documenting care is a core component of our work, and it is essential that functionality of any documentation system, whether this is on paper or digital, enables them to demonstrate their decision making and professional judgement in line with the NMC code.

Why now?

The digitisation of the NHS has made visible the volume of documentation that nurses are asked to produce, and the variation that exists, even within the same organisation.

The challenges of moving from traditional paper-based systems to digital include both the ‘what’ and ‘how’ to digitise documentation, as well as the cultural issues associated with reducing unwarranted variation and changing clinical practice.

With a growing number of organisations seeking to digitise nursing and midwifery documentation, addressing these issues, as a collective, is critical if we are to ensure practice is effectively supported by digital technology, and to be able to build on this to transform the way we work together, across organisational boundaries, to deliver seamless and coordinated care.

Long term ambition and where this guidance fits

The vision is to create a standardised framework for nursing documentation (adult and paediatric) across health and social care systems in England.

Maternity already has an information standard notice in place. However, work to scope and shape this identified nursing documentation as a long term issue impacting the workforce.

It also articulated challenges and opportunities that needed to be addressed and supported.

Read more about the exploratory background work for the information standard.

This guidance supports learning by:

• setting the direction towards standardising nursing documentation whilst supporting professional judgement and decision making
• reducing unwarranted variation in what is documented within and across organisations
• placing those we care for at the heart of care by focusing on their individual needs and ensuring we use the information they share with us to enhance the care we give
• proactively managing documentation
• supporting the use of technology to streamline documentation processes and support effective decision making
• supporting sharing of care needs information, using a common language, to enable seamless, continuity of care across place of care settings.

Who is this guidance for?

Nursing registrants are the main audience of this work. However, it is recognised that the core principles set out in this document relate to both nursing and midwifery. The scope has therefore been extended to be inclusive of midwifery.

In this guidance, there are following underpinning assumptions:

• the NMC code (2018) is used to guide nursing and midwifery documentation and decision making
• students and registrants practice and document decisions and care in line with the NMC code (2018)
• That nurses and midwives use their professional judgement in decision making and care delivery

Recommended approach

Nurses told us they wanted to be supported to change the way they practise and document care so there was a sense of shared ownership to record keeping.

Organisations are encouraged to involve care-based nurses and midwives in conversations about the design and implementation of new or updated record systems to ensure that they best support practise.
Introduction

Good documentation provides the evidence for safe high quality care. It provides clarity and aids good communication for the whole multidisciplinary team, supporting them to work together to deliver coordinated person-centred care.

A good record of nursing and midwifery care is based on the systematic approach that is the nursing and midwifery process: assess, plan, implement and evaluate. 

This systematic approach is reflected in the Care Quality Commission regulations for person centred care (regulation 9).

Guiding principles that underpin good documentation

These principles set out core expectations of documentation that nurses and midwives use whether they are using paper or a digital system to document the care they deliver.

Managing nursing documentation

Over time the documentation completed by nurses and midwives has grown in size and evolved in nature. Much of this will have been for good reasons but the opportunity exists to review what is documented and how, reduce unwarranted variation, and take steps to proactively manage documentation to ensure that it supports safe and effective practice now and into the future.

To support this:

• Ownership and management of nursing and midwifery documentation is the overall responsibility of the executive nurse/equivalent (or the delegated deputy) in the organisation.
• Nursing/midwifery documentation must be proactively managed to ensure the content is fit for purpose and supports safe and effective decision making and care, without placing undue burden on those being asked to complete it.
• Organisations must have appropriate central governance structures and controls in place to manage documentation. This should include overseeing development of new documentation, modification of documentation, destruction/removal of documentation, ensuring that documentation is aligned with organisational and national priorities, and ensuring equal consideration is given to the many different areas of care.
• There should be a core version of nursing documentation across the organisation.
• Digital organisations must have robust systems and processes in place to ensure safe and effective continuity of care in the event of planned and unplanned downtime.
• Where there are dual systems in place, for example paper and digital systems, there should be a standardised approach to nursing documentation so that the same thing is documented in the same way. This approach should be defined in a documentation policy. The only variation should be during the roll out of new ways of working. To minimise risk, roll out schedules should be time sensitive and supported by pre-defined monitoring and review points.
• In line with NMC guidance, unnecessary abbreviations should be avoided because the meaning of abbreviations may vary in different organisations and can compromise patient safety.

Person centred approach to care

People should remain at the heart of care.

To support this:

• The person receiving healthcare/care should be enabled to be an active partner in care, including being involved in planning and documentation of care and any decisions and preferences as they express.
• Individuals should be enabled to access their care record via the NHS App, or, where used, an organisations patient portal or paper hand held record.
• Use of the PRSB ‘About me’ standard should be routine (see useful resources for details). 
• Individuals should be supported and empowered to contribute to their care and the information they provide be used by registrants to support decision making (see useful information for shared decision-making resources).
• Where the person is unable to be an active care partner, the identified carer/person with legal power of attorney for health and welfare should be included and contribute to the plan of care.
• Documentation should be age appropriate.
• The structure of documentation should support transition of care across all care settings.

Nurses as part of a multidisciplinary team

A person using health and care services will come into contact with a large number of professionals working as a multidisciplinary team (a group working together across healthcare boundaries).

To support this:

• The nursing record should be easily identifiable and be framed as a core part of the record that the whole multidisciplinary team can access.
• Nurses should have access, at the point of care, to the full team’s documentation and the shared care record, to inform decision making and support continuity of care.
• The multidisciplinary team should share and re-use each other’s documentation, where safe to do so, to reduce the need for repetitive questioning.

Digital tools and usability

Documentation should be intuitive to the process of assess, plan, implement and evaluate whilst supporting the use of professional judgement and decision making in real time. 

To support this, system design for nursing and midwifery documentation must:

• facilitate intuitive data entry.
• support the ability for data to be entered once and reused, where clinically appropriate and safe to do so, to avoid the need to repeat data entry and to reduce risk of asking the patient same question multiple times.
• support searching the record.
• enable use of support tools, like spell check.
• be traceable to the person who documented.
• use clinical decision support tools to support safe and effective decision making and streamlined documentation at the point of care, whilst avoiding alert fatigue.
• use standardised terminology that is embedded into nursing documentation in a way that retains context, facilitates data entry and retrieval, and supports decision making through appropriate links, for example between practice and outcomes and out to actionable intelligence. This terminology should support common and precise language that all nurses understand so that it can be meaningfully shared.
• be in a structured data format except for description of variation and evaluation of care.
• routinely use tools such as exception reporting or ‘within defined limits’, with variation being documented in narrative free text.
• visualise data in a way that enables registrants to see trend over time.
• enable registrants to see information that is held in national systems, such as the child protection information system, reasonable adjustment flag, emergency mental health care plans, and the shared care record at the point of care, so they are able to provide person centred and coordinated care across care settings.
• support nurses to document and share documentation within and across the health and care system in a way that is meaningful and supports continuity of coordinated care for the person.
• support data extraction from the care record and use of business intelligence tools to support reporting, service evaluation, auditing and research.
• reflect national documentation and reporting standards including those set out within information standards notices and by the Professional Records Standards Body (PRSB) that are relevant to nursing and midwifery.
  • This includes:
    • PRSB Core information standard
    • PRSB About me
• leverage patient generated data, including ‘This is me’/’what matters to me’, to support understanding of individual preferences/needs.
• ensure strong foundations to enable nurses and midwives to harness technology such as artificial intelligence, predictive analytics, voice recognition and ambient intelligence.
• disable tools such as ‘copy and paste’ functionality as they pose risks to quality and safety. Alternatives such as ‘enter data once’ and ‘re-use’ to be used where there is a need to duplicate information.

Sharing of information to support continuity of care

People receive health and care in a number of different care settings. Therefore, it is essential that we communicate effectively with professionals involved in care decision making and share information across organisational boundaries to support safe and effective continuity of care.

To support this:

• Organisations should have the relevant information governance agreements in place to support and enable all members of the MDT to have direct access to relevant health records safely and securely, including those employed by other organisation, e.g., social workers.
• When an individual is going to require continuing care or follow up from a health care professional, functional care needs should be shared as part of discharge.

Audit of record keeping

Good data supports nurses to articulate their contribution to care whilst providing evidence on nurse sensitive outcomes and associated key performance indicators for internal and external review.

To support this:

• Data collection that supports audit, service evaluation, research and national reporting should not require additional clinical documentation to be completed over and above that which is required to record care.

Documenting the nursing and midwifery process

The content of documentation must be focused around the nursing/midwifery process: assess, plan, implement and evaluate.

Registrants should be able to see, understand and articulate the link between the steps in the process.

Documentation must not require a blanket approach. For example, patients may not require a full and detailed assessment, unless there is an identified clinical need.  The need may be clinically identified or be the person priorities of care.

Documentation must enable and support nurses and midwives to use and document their professional judgement and decision making, for instance to determine the need to complete an assessment is based on the needs of the individual.

If the individual is independent and this is not anticipated to change, there should be no need to complete a moving and handling assessment.

Assessment

Assessment is part of a decision-making process.

An assessment allows registrants to collect information to support a professional judgement about needs and decisions about nursing interventions required to address the needs.

A holistic assessment of need may include, but may not be limited to, the following: 

• Physical wellbeing including pain and comfort, nutrition and hydration, fetal wellbeing.
• Psychological, emotional and mental wellbeing, including mood scales.
• Social context and needs, including social determinants of health and protected characteristics.
• Cultural and spiritual care needs.
• Safeguarding and risks or concerns.
• Mental health and related legal requirements.
• Mental capacity and related legal requirements.
• Reasonable adjustments that may be required.
• Person centred needs as defined in documents such as the ‘PRSB About me’ standard or Alzheimer Association ’This is me’.
• Identified education and training needs to support self-care and management as appropriate.

Assessment tools can aid information collection by providing structure to make that judgement and decision.

Any tools used to support decision making should be evidence based. See a list of evidence based tools.

Plan

The next step in the process is care planning.

Good care plans will:

• be person centred and reflect individual needs (actual or potential).
• include evidence-based interventions that support safe, effective, outcome focused care, and include understanding of the persons personal context (safety, end of life care etc).
• enable and support registrants to use professional judgement to determine the plan of care required to support the individual.
• ensure the nursing/midwifery team are working cohesively toward the same goals.

Implement

Implementation in this context is about delivery of the defined care plan.

Documentation in this phase will facilitate the documentation of the actual care given and observations, including vital signs, changes to skin etc.

Evaluation

In this context the evaluation is considering the impact of the plan of care on meeting needs and defining any changes that may be required.

Documentation may be simple, for example care as planned or narrative to define variation and revisions to the plan of care to address needs. All narrative should be factual and succinct. 

Background

Discovery

In 2020, the digital nursing team, in what was then NHSX, commissioned the Professional Records Standards Body (PRSB), the leading organisation that works with professionals and the public to define the standards needed for good care records, to undertake a discovery report to investigate the feasibility, benefits, risks and challenges of developing a national nursing documentation standard.

The work used a mixed methodology including interviews, focus groups and literature review.

The report concluded that there is broad support and a strong proven case for the benefits that would accrue from developing a nursing standard.

There was a recommendation that the standard should go further than standardising documentation in systems with templates and embedded classifications and coding systems in order to work effectively in an integrated system.

The recommendation was that the standard should be interoperable and fully integrated into shared care records where the provenance and contextualisation of patient/citizen information is paramount for clinical safety.

The report coincided with the findings of the digital maturity assessment of digitally enabled nursing conducted in 2020 by the digital nursing programme, which identified that a priority focus should be standardisation of nursing processes and documentation.

Based on these recommendations, work commenced to scope the content of a nursing standard

Scoping

To inform and develop the nursing documentation standard, work was commissioned from 2 sources:

• research from the University of Huddersfield.
• standard development from the Professional Records Standards Body (PRSB) including drafting of nursing standard.

The research commissioned from the University of Huddersfield was undertaken by leading nursing informatics researchers.

It sought to build on a literature review, published by these researchers in 2019, that critically examined existing approaches to nursing records and began to identify possible new requirements.

This research examined reinterpreting the nursing record for an electronic context, using methodology that included focus groups in the UK and US and case studies from the UK.

The PRSB work sought to scope the standard and proposed content and develop a content requirement specification for the key aspects to be digitised. The methods for this work included individual interviews (nurses and other health care professionals), focus groups (adult nurses, paediatric nurses and patients), mapping of current examples of nursing documentation used in practice, literature review, review of regulatory requirements, review of other UK nursing data sets and surveys for focus group attendees.

Themes and emerging issues from the scoping

Overall, the scoping identified nursing documentation as a ‘wicked’ problem.

The approach to nursing documentation was not felt to have changed significantly since the Roper, Logan and Tierney model of nursing was introduced in the 1980s (Roper et al 1980) other than the introduction of a plethora of risk assessments.

The key themes and issues emerging from this work included:

• A lack of understanding of what good documentation looks like in a digital context.
• Nurses struggling to see the art of the possible using digital technology, both in a general sense but also in relation to nursing documentation.
• The systematic approach to nursing care, the nursing process, being noticeably absent (despite this being part of pre-registration education).
• The burden of documentation having impacts including:
  • the high focus on a blanket approach to risk assessing those we care for is stifling the ability of a nurse to use their professional judgement. It is also limiting personalisation of care based on the person’s needs.
  • the volume of documentation takes significant time to complete (hours).
  • time constraints and frequent movement in the hospital setting impact the potential accuracy of the assessment.
  • nurses not trusting or confident of the assessment made by other nurses, resulting in them repeating the assessment.
  • a ‘task focus’ culture to try and complete all the assessments. Nurses considered that very little of what was assessed when first meeting a person was used to inform a plan of care or looked at later in a journey.
  • nurses do not see the purpose of much of what they document but feel powerless to change this.
  • there is little standardisation of risk assessment tools within a care setting or across care settings. The impact of this is that the language used by nurses may have little or no meaning outside the organisation.
  • limited links between children’s and young people’s nursing records and those of adults meaning that transition not always seamless.
• Much of the documentation of nurses could be undertaken by a number of different professionals other than nurses, and if shared across organisational boundaries in a digital format would offer significant opportunities to reduce documentation burden more generally.
• Information held in shared care records and on the NHS spine, for example reasonable adjustment flags, is not easily accessible at the point of care.
• The perception that audit needs are driving the risk assessment process (and that this is being driven by senior nurses).
• A fear of litigation that is resulting in defensive documentation (and voluminous narrative).
• Many digital systems being considered suboptimal for nursing needs.
• Lack of ownership and management of nursing documentation.

Despite this perception of what is not working well, the work also identified a hunger for transformation and desire to be a part of innovation.

It also pointed to the need to redefine the future of nursing documentation in a digital world with an approach that features the following:

• An approach that has wide professional engagement and supports innovation.
• An approach that sets out a range of principles to be applied to nursing documentation to ensure it adds value to an individual’s pathways of care.
• Digital tools that can be used to support nursing in documentation care in a way that makes it easy to do the right thing.
• The need for a supporting infrastructure.
• Structural supports that ensure nurses own nursing documentation and are supported to use it effectively.

The findings from the scoping have been used to form the basis of this guidance.

Recording keeping for nurses and midwives

The nursing and midwifery code (2018) sets out the standards for record keeping by registrants.

In summary: 

Nursing and Midwifery Council Code (2018)

The NMC code sets out the standards for record keeping in section 10.

The code includes the need to:

• keep contemporaneous clear, factual and accurate records
• use a systematic approach to identify need and how to manage risks
• document in a language that is free form unnecessary abbreviations or jargon
• keep all documentation secure.

Legal and regulatory aspects of documentation

Records management code of practice 2021

The Records management code of practice 2021 sets out the legal obligations for the management of NHS records. It sets out the legal frameworks and details the responsibility of NHS employees have for records used, or created in the scope of their work, regardless of the format of the records; paper, digital, or otherwise.

Care Quality Commission

The regulatory body, the Care Quality Commission, sets out regulations that ensure providers meet the requirements of the Health and Social Care Act 2008 (regulated activities).

Regulation 9 seeks to ensure that people using services received personalised care, based on an assessment of their needs and preferences.

It is expected that organisations work in partnership with people to make reasonable adjustments and provide support to help them understand and make informed decisions about their care and treatment options, including expect to which they manage these themselves.

This should include taking into account people’s capacity and ability to consent.

Regulation 17 states “providers must securely maintain accurate, complete and detailed records in respect of each person using the service”.

NHS Resolution

NHS Resolution, an arm’s length body of the Department of Health and Social Care, handles negligence claims on behalf of NHS organisations.

They manage seven clinical negligence schemes, one of which is the Clinical Negligence Scheme for Trusts. This is a premium paid to NHS Resolution for insurance which covers NHS organisations for clinical negligence claims.

It is noted that 11% of claims handled by NHS Resolution are for obstetric incidents, these amount to 59% of the total value of claims.

The NHS Resolution guide for healthcare providers supports staff to prepare for an inquest.

The Health Care Safety and Investigation Branch

The Healthcare Safety and Investigation Branch (HSIB) is the independent national investigating body for patient safety in England.

They are a non-blame organisation that conduct national and maternity investigations to improve patient safety at national level.

Their mission is to “improve patient safety through professional safety investigations that do not apportion blame or liability”.  

Coroner

A coroner is an independent judicial officer, often a lawyer or doctor. They investigate deaths that have been reported to them, request post-mortems, and hold inquests known as Coroner’s Court.

A coroner investigating the death of a patient will request all documentation of the patient’s care, their medical records, and statements of facts from clinicians.

Any nurse or midwife can be called by a Coroner to give evidence at an Inquest if they have been involved in the care of a patient that has died.

The Royal College of Nursing and Royal College of Midwives provide support for nurses and midwives who have been asked to provide a statement of facts to the coroner. They also provide guidance for writing statements.

References

Care quality commission regulations. Available on line: https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulations-service-providers-managers

Healthcare Safety Investigation Branch. (2021). Home. [online] Available at: https://www.hsib.org.uk/

National Health Service Transformation Directorate (2021) Records Management Code of Practice 2021. [online] Available at: ): https://transform.england.nhs.uk/information-governance/guidance/records-management-code/

Nursing and Midwivery Council (2018) The Code. Professional standards of practice and behaviour for nurses, midwives and nursing associates. NMC, London.

Royal College of Nursing (2015) Record Keeping. The Facts. Available at:

https://www.rcn.org.uk/Professional-Development/publications/rcn-record-keeping-uk-pub-011-016

National Health Service Resolution 2022. Online: https://resolution.nhs.uk/

Appendix 1 – evidence based assessment tools

Core risk assessment tool: Malnutrition universal screening tool (MUST)

Findings: screening tool limitations

The use of existing screening tools for the nursing home population carries limitations, as none performs better than “fair” in assessing nutritional status or in predicting outcome. Also, no superior tool can be pointed out. This systematic review implies that further considerations regarding malnutrition screening among nursing home residents are required.

Reference: A systematic review of malnutrition screening tools for the nursing home setting – PubMed (nih.gov)

Findings: development of new screening tools

Not one single screening or assessment tool is capable of adequate nutrition screening as well as predicting poor nutrition related outcome. Development of new tools seems redundant and will most probably not lead to new insights. New studies comparing different tools within one patient population are required.

Reference: Nutrition screening tools: does one size fit all? A systematic review of screening tools for the hospital setting – PubMed (nih.gov)

Findings: nutritional screening

There are many nutrition screening tools in use across the world.  However, the most commonly used screening tool in all care settings in the UK is the ’Malnutrition Universal Screening Tool’ (‘MUST’). This was developed and launched by BAPEN in 2003. It was designed to be valid, reliable, and easy to use in all adults. It can detect over-nutrition as well as under-nutrition and is linked to a flexible care plan. It is not designed to detect deficiencies in or excessive intakes of vitamins and minerals. In December 2015, BAPEN launched the first Malnutrition Self-Screening Tool for use by individuals and/or their carers who are concerned about malnutrition.

Reference: Nutritional Screening (bapen.org.uk)

Findings: five malnutrition screening tools

The quick-and-easy malnutrition screening tools (MST and SNAQ) are suitable for use in an hospital inpatient setting. They performed as well as the comprehensive malnutrition screening tools (MUST and NRS-2002) on criterion validity. However, MUST was found to be less applicable due to the high rate of missing values. The MNA-SF appeared to be not useful because of it low specificity.

Reference: Comparison of five malnutrition screening tools in one hospital inpatient sample – Neelemaat – 2011 – Journal of Clinical Nursing – Wiley Online Library

Findings: adult malnutrition

This review provides an analysis of validity, agreement, and reliability of tools to screen adults for malnutrition, regardless of their age, medical history, or location. No tools were found with high validity, reliability, and strong supportive evidence. Tools most often achieved moderate validity, agreement, and reliability, and had large variations in individual results. The minimum validity and reliability of tools to screen adults for malnutrition should be established to shape future research. Cost data for the screening process should be obtained and examined

Reference: Adult Malnutrition (Undernutrition) Screening: An Evidence Analysis Center Systematic Review – PubMed (nih.gov)

Core risk assessment tool: National early warning score (NEWS)

Findings: national early warning score

NEWS2 has received formal endorsement from NHS England and NHS Improvement to become the early warning system for identifying acutely ill patients – including those with sepsis – in hospitals in England. Due for review in 2023

Reference: National Early Warning Score (NEWS) 2 | RCP London

Findings: in hospitalised patients

The finding that NEWS or NEWS2 performance was good and similar in all five cohorts suggests that amendments to NEWS or NEWS2, such as the addition of new covariates or the need to change the weighting of existing parameters, are unnecessary when evaluating patients with COVID-19. Our results support the national and international recommendations for the use of NEWS or NEWS2 for the assessment of acute-illness severity in patients with COVID-19.

Reference: The performance of the National Early Warning Score and National Early Warning Score 2 in hospitalised patients infected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) – PubMed (nih.gov)

Findings: score when assessing possible COVID-10 patients in primary care?

NEWS2 is an early warning score developed pragmatically for use in hospital inpatient settings and based on data routinely available to hospital staff; Research suggests that NEWS2 is useful in stratifying patients and triggering intervention in hospital settings and that it may add value in pre-hospital setting when used by ambulance staff.

Reference: NEWS (or NEWS2) score when assessing possible COVID-19 patients in primary care? – The Centre for Evidence-Based Medicine (cebm.net)

Findings: early warning scores

Very low and high EWS are able to discriminate between patients who are not likely and those who are likely to deteriorate in the pre-hospital setting. No study compared outcomes pre- and post-implementation of EWS so there is no evidence on whether patient outcomes differ between pre-hospital settings that do and do not use EWS. Further studies are required to address this question and to evaluate EWS in pre-hospital settings.

Reference: Can early warning scores identify deteriorating patients in pre-hospital settings? A systematic review – ScienceDirect

Core risk assessment tool: FALLS

Findings: systematic review of fall risk screening tools

The identified tools do not demonstrate predictive values as high as needed for identifying older inpatients at risk for falls. For this reason, no tool can be recommended for fall detection. More research is needed to evaluate fall risk screening tools for older inpatients.

Reference: Systematic review of fall risk screening tools for older patients in acute hospitals – Matarese – 2015 – Journal of Advanced Nursing – Wiley Online Library

Findings: Fall risk assessment

Evidence for the best choice of FRAT for use in LTC remains limited. Further research is warranted for the PHFRAT, recommended for use in LTC by best practice guidelines, before its establishment as the tool of choice for these clinical settings.

Reference: Fall risk assessment tools for use among older adults in long‐term care settings: A systematic review of the literature – Anglia Ruskin University (exlibrisgroup.com)

Findings: validate fall risk assessment tools for use with older adults

The large number of tools reflects a strong tendency to create new instruments, with only a few of them recommended. To reach a gold standard, it would be good to try to validate the existing scales in more countries instead of creating new one.

Reference: Validated Fall Risk Assessment Tools for Use with Older Adults: A Systematic Review – Anglia Ruskin University (exlibrisgroup.com)

Findings: Practical and validated tools to assess falls risks in primary care

Given that none of the falls risk assessment tools had sufficient predictive performance, other ways of assessing high falls risk among independently living older people in primary care should be investigated. For now, the most suitable way to assess falls risk in the primary care setting appears to involve asking patients about their falls history. Compared with the other five tools, the falls history requires the least amount of time, no expensive equipment, no training and no spatial adjustments. The clinical judgement of healthcare professionals continues to be most important, as it enables the identification of high falls risk even for patients with no falls history.

Reference: Practical and validated tool to assess falls risk in the primary care setting: a systematic review – Anglia Ruskin University (exlibrisgroup.com)

Findings: fall risk screening tools for older inpatients

The identified tools do not demonstrate predictive values as high as needed for identifying older inpatients at risk for falls. For this reason, no tool can be recommended for fall detection. More research is needed to evaluate fall risk screening tools for older inpatients.

Reference: Systematic review of fall risk screening tools for older patients in acute hospitals – Anglia Ruskin University (exlibrisgroup.com)

Core risk assessment tool: Skin assessment

Findings: new pressure ulcer risk assessment instrument

The PURPOSE-T evaluation facilitated the initial validation and clinical usability of the instrument and demonstrated that PURPOSE-T is suitable of use in clinical practice. Further study is needed to evaluate the impact of using the instrument on care processes and outcomes.

Reference: Clinical evaluation of a new pressure ulcer risk assessment instrument, the Pressure Ulcer Risk Primary or Secondary Evaluation Tool (PURPOSE T) (wiley.com)

Findings: tissue viability

No risk-assessment tool is perfect and further research is required to enhance the validity of the Waterlow tool, possibly through alteration of weighting, categories and thresholds tor a variety to patient groups. An advantage to the Wateriow tool is that it differentiates between ‘at risk’, “high risk’ and Ver^’ high risk’ status and appears more suitable than other tools for a wider age group. It can also be adapted and modified to meet the needs of different patient populations. Further education in the limitations and uses to the Waterlow tool is required to achieve greater reliability’. The tool should not be used as the sole indicator tor resource allocation but should be used in conjunction with clinical judgment and advice from a tissue viability nurse. 

Reference: Tissue viability. An evaluation of the Waterlow pressure ulcer risk-assessm…: EBSCOhost

Findings: risk of pressure injury in acute care

This study provides further evidence of poor predictive validity of the waterlow scale. A suitably powered randomized controlled trial is urgently needed to provide definite evidence about the usefulness of water low scale compared with other screening tools and with clinical judgement.

Reference: Validity of the Waterlow scale and risk of pressure injury in acute care.: EBSCOhost

Findings: clinical judgement

The interaction of education, clinical judgement and use of risk assessment sakes has not been fully explored. It is not known which of these is most important, nor whether combining them results in better patient care.

Reference: Norton, Waterlow and Braden scores: a review of the literature and a comparison between the scores and clinical judgement – Anthony – 2008 – Journal of Clinical Nursing – Wiley Online Library

Findings: assessing pressure ulcers in Turkey

The Braden Scale was used in these studies for forming samples by identifying high-risk patients. Two studies evaluated the reliability of the Braden Scale, whereas 7 other studies calculated the reliability coefficient. Only 1 study included results for sensitivity, specificity, positive predictive value, and negative predictive value (which represent the predictive criteria of assessment tools). Four studies indicated cutoff values, which varied between 14 and 18.A general evaluation of these studies’ results revealed limited evidence of effective risk assessment by the Braden Scale.

Reference: The Use of the Braden Scale in Assessing Pressure Ulcers in Turkey: A Systematic Review – PubMed (nih.gov)

Findings: assessing pressure ulcers in Turkey

The inter-rater reliability of PURPOSE-T was demonstrably poor on three subdomains: perfusion status, mobility and sensory perception (Coleman et al, 2018). It is likely that this reflects clinimetric issues with the methods used to assess these specific risks and may be confounded by users’ limited knowledge (Siedlecki and Albert, 2017). Overall, the tool appears to produce reliable and consistent assessment outcomes between experts and non-experts (Coleman et al, 2018). Determining the sensitivity and specificity of PURPOSE-T remains difficult, due to the ethical considerations inherent in obtaining definitive outcomes with which to compare initial risk assessments (Lalkhen and McCluskey 2008). Further research is needed to provide robust evidence on the clinimetric values of PURPOSE-T, including studies with patient populations in which it has not been tested, for example, children, critically ill individuals and psychiatric patients.

Reference: British Journal of Nursing – A clinimetric analysis of the Pressure Ulcer Risk Primary or Secondary Evaluation Tool: PURPOSE-T

Appendix 2 – useful reading and links

Personal wishes

• Professional Standard Record Body About me standard
• Alzheimer association ‘This is me’

Shared decision making- useful websites

• NHS England
• NICE

Standards

• Better nursing records for better nursing care – PRSB
• Digital Health. (2017). About Professional Record Standards Body and their role in digital health

Legal and regulatory issues

• GOV.UK (2018). Data Protection Act
• Inquests: A guide for health providers Supporting staff to prepare for an inquest
• Legislation.gov.uk. (2010). Public Records Act 1958
• Legislation.gov.uk. (2014). The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
• Maternity incentive scheme -year four
• RCM. (n.d.). Branch templates

Appendix 3 Editorial board membership

We are grateful to members of the editorial board for their help with developing this guidance. The board included representation from across nursing and midwifery:

• Helen Balsdon (Chair), Head of Digital Nursing (Deputy CNIO), NHS England
• Jane Murkin, Strategic Nurse Advisor Patient Safety and Improvement, NHS England
• Wendy Fowler, Nursing Education Adviser Professional Practice, Nursing and Midwifery Council
• Dawn Dowding, Professor in Clinical Decision Making, University of Manchester
• Julia Gudgeon, National Digital Midwife Lead for Maternity, NHS England
• Louise Parker, UK Professional Lead – Long term conditions, Royal College of Nursing
• Caron Sanders-Crook, Operations Manager, Canford Healthcare (social care representative)
• Paula Anderson, Chief Nursing Information officer, University College Hospitals London
• Sarah Newcombe, Regional Chief Nursing Information officer / Chief Nursing Information officer, NHS England (London region) /Great Ormond Street Children’s Hospital
• Jessica Read, Deputy Chief Midwifery Officer, NHS England
• Saritha Prathipati, Florence Nightingale Foundation Digital Nursing Leadership Fellow, NHS England

Supporting contributions made by:

• Dawn Cross, Florence Nightingale Foundation Digital Midwifery Leadership Fellow, NHS England.

Publication reference: PR1695