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Digital patient records: nurses in Wales trial new system to ‘standardise documentation’

Scheme set up in response to inconsistent paper-based record-keeping
Nurse using a digital handheld device

Scheme set up in response to inconsistent paper-based record-keeping

Nurses in Wales are trialling a new digital platform to help standardise patient records.

The digital Welsh Nursing Care Record (WNCR) system was developed in response to an audit that found paper-based record-keeping was not always consistent or easy to read, and that recording-keeping varied between health boards.

Patient assessment using a digital handheld device

Digital versions of forms, such as risk assessments and adult inpatient assessments, were introduced last month and are being piloted throughout March in selected adult inpatient wards across Wales.

Nurses will be able to complete assessments at a patients bedside using a tablet computer or other handheld device.

Bringing consistency to patient documents

NHS Wales Informatics Service national clinical informatics lead for nursing, Frances Beadle, said the idea was to standardise

Scheme set up in response to inconsistent paper-based record-keeping


Picture: iStock

Nurses in Wales are trialling a new digital platform to help standardise patient records.

The digital Welsh Nursing Care Record (WNCR) system was developed in response to an audit that found paper-based record-keeping was not always consistent or easy to read, and that recording-keeping varied between health boards.

Patient assessment using a digital handheld device

Digital versions of forms, such as risk assessments and adult inpatient assessments, were introduced last month and are being piloted throughout March in selected adult inpatient wards across Wales.

Nurses will be able to complete assessments at a patient’s bedside using a tablet computer or other handheld device.

Bringing consistency to patient documents

NHS Wales Informatics Service national clinical informatics lead for nursing, Frances Beadle, said ‘the idea was to standardise nursing documentation with one standard nursing language’.

She added that the trial has already received positive feedback from nurses, with some asking if they can continue using the WNCR after the trial finishes.

‘One nurse said it had helped them to fill out the documentation appropriately, because the digital system demonstrates how the form is supposed to be filled out, unlike the paper form,’ said Ms Beadle.


Screenshot of a video that explains the digital system to staff

The WNCR was created with input from nurses, clinicians and allied health professionals, and a clinical nursing lead in each health board has led the introduction of the new documents.

It is hoped that the digital system will be implemented throughout Wales so that healthcare professionals can access a patient’s records wherever they are in the country.

Ms Beadle said data will be evaluated at the end of the trial to examine the WNCR’s effect on patient care and nurses’ workloads.

The digital forms will be trialled in more wards in Wales later in the year.


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