New standard simplifies patient notes, lifting burden on nurses
Unified approach on patient information across hospital, community and social care settings will free up nurses’ time
Patient information used to inform care will become easier to document with the launch of a new standardised approach.
The nursing care needs standard creates a unified approach to nursing documentation across hospital, community and social care settings.
It aims to free up nurses’ time to provide care for patients, reduce variation in patient notes and support the delivery of more effective care in nurse-led areas.
Data from the Safer Nursing Care Tool suggest nurses spend as much as 15% of their time documenting care and a further 10% looking for patient information.
The new standard, developed by the Professional Record Standards Body (PRSB), is designed to reduce this administrative burden through standardising the information that a nurse in a care home or community setting can access and share in the same way as a hospital nurse.
Aiming to improve continuity of care between healthcare settings
The PRSB said it hoped it would improve continuity of care between healthcare settings. The draft standard is available for use now, and the PRSB is seeking the views of its members and professional bodies, including the RCN, to finalise it.
Interim chief nursing information officer for NHS England Helen Balsdon said: ‘A unified approach to nursing practice across care ensures consistency and amplifies the patient voice in their own care journey. By having a standard, we can begin to create a seamless care experience.’
The standard was informed by a survey of more than 400 nurses and midwives, alongside consultation with clinical system suppliers.
It focuses on a patient’s eating and drinking, mobility, toileting and continence, personal hygiene, skin, and medication self-management.
Making nurses’ working lives easier, more efficient and rewarding
The information will then be accessible in a patient’s care record by nurses across different settings, enabling them to make informed decisions about patient care.
PRSB chair Maureen Baker said: ‘Nursing is fundamental to delivering high quality care whether in hospital or the community so it’s crucial that we support nurses’ work as much as possible.
‘To do this it is key that we recognise the administrative burden on nurses of documenting and sharing care information and provide them with solutions that make their working lives easier, more efficient and rewarding.’
The standard is part of a wider project by NHS England to embed standardised nursing documentation across the health and care system.
Guidance for creating standardised nursing documentation in England was published in September.
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Further information
- NHS England (2023) Towards a unified vision of nursing and midwifery documentation
- Professional Records Standards Body (2023) Nursing Care Needs Standard
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