Health Visiting and School Nursing Service Clinical Record Keeping Re-Audit 2014/15

Transcription

1 Health Visiting and School Nursing Service Clinical Record Keeping Re-Audit 2014/15 Chris Buzzard, Health Visiting & School Nursing Service Manager Nicy Turney, Professional Lead, Health Visiting. Maggie Clarke, Professional Lead, School Nursing Rosie Jones Clinical Governance Co-Ordinator Audit Period: November 2014 Report Date: February 2015

2 Summary A record keeping audit is undertaken on an annual basis as part of the Leicestershire Partnership NHS Trust audit programme to ensure that members of staff are maintaining clinical records in accordance with Policy. The quality of record keeping is a reflection of the standard of professional practice. Clinical records are a vital tool for communication; therefore it is imperative for records to contain sufficient and comprehensive detail about the service user s condition, treatment and wishes about a verbal handover. Methodology All Health Visitors and School Nurses in the Health Visiting & School Nursing team took part in the audit an collected the data across a one month period using a peer-review buddy system. A total of 560 records were audited, comprising 25 Health Visiting Records and 15 School Nursing records for each of the fourteen neighbourhoods across Leicester City and County. Key findings Section 2012/13 Compliance 2014/15 Compliance Progress Service User Demographics 84% 85% Chronological order 59% 83% Accuracy 78% 92% Relevant Clinical Information 77% 87% Evidence of Service User involvement 67% 95% Safeguarding 72% 90% SystmOne 84% 91% Overall 77% 88% Total number of case notes audited of 19 Summary Error! No text of specified style in document.

3 Contents Page Background 4 Aim 4 Standards 5 Method 5 Findings 6 9 Comments 9-13 Recommendations 14 Audit Tool 15 Distribution List 16 Action Plan 16 Abbreviations LPT Leicestershire Partnership NHS Trust Error! No text of specified style in document. Contents 3 of 19

4 Background Clinical records are a fundamental part of patient care, they reflect the quality and the safety of care that is delivered to our service users. Clinical records not only provide a description of the service user s condition, they also provide information on the planned care of treatment, the type of care that is provided to them, and the evaluation of the outcome of care or treatment. In addition, they are a tool that supports the delivery of care that is provided by recording the advice given to service user s wishes regarding their care or treatment (consent). The quality of record keeping is a reflection of the standard of professional practice. Clinical records are a vital tool for communication; therefore it is imperative for records to contain sufficient and comprehensive detail about the service user s condition, treatment and wishes without a verbal handover. The body charged with regulating the quality of care provision in England, the Care Quality Commission (CQC Outcome 21) has declared the quality of records as an essential standard for organisations providing health care services, expecting them to be accurate and fit for purpose. A two year record keeping audit programme has been undertaken to cover all services within the FYPC Division. Year 1 (2012/2013) examined the Communities and Youth Services and Year 2 (2013/2014) examined Children & Families Services. This ensures that each member of staff were maintaining clinical records in accordance with the Record Keeping and Management of the Quality of Health Records Policy. Health Visitors specialise in preventative health and health promotion. The team provide universal services to all children and families, which helps them to understand and identify individual health needs. Health Visitors are responsible for leading the Healthy Child Programme (2009) to children 0-5yrs and their families. An effective, universal, preventative and early intervening service has a crucial role in working collaboratively to identify the number of at risk children and young people. The service aims to reduce the risk of this client group becoming the most vulnerable adults in the future. Early intervention and long term investment will support the children, young people and their families to reach their full potential. School Nurses are responsible for delivering cost-effective public health programmes or interventions to improve health outcomes for school-aged children and young people (5-19 yrs). This includes reducing childhood obesity, under 18 conception rates, prevalence of chlamydia and management of mental health disorders. The School Nursing Service offers a structured approach to delivering the Healthy Child Programme (5-19), providing public health advice and ensuring the emphasis is on providing early help to children and young people from School Nurses. Health Visiting and School Nursing Services work together to ensure children, young people and families are supported. Aim Objectives To ensure that members of staff are maintaining clinical records in accordance with Record Keeping and Management of the Quality of Health Records Policy. Also to identify the areas of poor practice and to improve services by targeting them specifically and to implement the recommended changes to improve the overall standard of Record Keeping within the FYPC Division. 4 of 19 Background Error! No text of specified style in document.

5 Standards Standards/Guidelines/Evidence Base The Record Keeping and the Management of the Quality of Health Records Policy identifies that the following information must be present on all clinical records to form a core set of criteria for all clinical services: Full name written as surname first, followed by forenames in block capitals. Address and postcode. Telephone number (if available) Date of birth Gender NHS number/maracis/hiss Number GP Practice: name and address Emergency contact: names and address Next of Kin: name and contact number Any allergies A full medication history and all medicines Ethnic origin In addition, there were a series of service-specific criteria that were developed in collaboration with the service leads to investigate and tailor the service requirements. Previously identified from audits, it was anticipated the service-specific criteria will be informed by areas of risk and poor performance. It is widely acknowledged that all records should be compliant with best practice, with a compliance rate of 100% in all aspects of record keeping. However, this is difficult for any organisation to achieve, therefore to distinguish best practice from poor practice the threshold of compliance was set at 90% with the view that services will pursue 100% by demonstrating year on year improvements. To help identify priorities for action planning, the following standards were set: Above 90% acceptable 89% - 70% partially acceptable Below 69% minimal Method The audit tool was tailored and developed in collaboration with the service leads from the Health Visiting and School Nursing team and ed to locality service managers for comment. The documentation covered several areas of record keeping: Service User Demographics (Full Name, address, date of birth, NHS number, etc) Chronological Order Accuracy Relevant Clinical Information Evidence of Service User Involvement Safeguarding SystmOne Error! No text of specified style in document. Standards 5 of 19

6 Service specific criteria for the records in the Health Visiting and School Nursing team were reviewed and incorporated with the core set of criteria from the Record Keeping and Management of the Quality of Health Records Policy which was then turned into Formic; a paper based audit collection tool. All trained staff in the Health Visiting & School Nursing team service were audited. Data was collected across a one month period; two records per health visitor and school nurse were randomly selected to audit and the responses were then noted into the formic audit tool. Once all the tools had been completed by the Health Visiting & School Nursing team, a member from the clinical audit team had arranged to collect the tools from their base. Therefore, the audit tools were scanned onto the Formic Software and downloaded onto Excel for further statistical analysis. The overall compliance score by section was calculated through the data count. Sample & data source In total, 560 records were audited, comprising 25 Health Visiting Records and 15 School Nursing records for each of the fourteen neighbourhoods across Leicester City and County. Audit type This is a retrospective case note re-audit. See Appendix 1 on p.15 for a copy of the audit tool. Caveat This report only covers the Health Visiting & School Nursing Team within FYPC; a separate record keeping audit is being completed for the other services within FYPC. Findings Responses received A total of 560 patient records were reviewed by the Health Visiting & School Nursing Team, all were electronic records. 25 Health Visiting Records and 15 School Nursing records for each of the fourteen neighbourhoods across Leicester City and County were completed. 6 of 19 Findings Error! No text of specified style in document.

7 Audit findings Table 1 Audit results (in comparison with a previous audit) Criteria 2012/13 Compliance 2014/15 Compliance Progress Service User Demographics 84% 85% Chronological Order 59% 83% Accuracy 78% 92% Relevant Clinical Information 77% 87% Evidence of Service User Involvement 67% 95% Safeguarding 72% 90% SystmOne 84% 91% Overall 77% 88% Total number of casenotes audited HEALTH VISITING Service User Demographics Q Question Total 1 Full name 100% 2 NHS Number 100% 3 Electronic record has been matched to the NHS Spine 100% 4 Address, including postcode 100% 5 Gender 100% 6 Date of Birth 100% 7 Telephone number 98% 8 GP Name 94% 8a GP Address 91% 9 Ethnicity 93% 10 Next of Kin contact name 80% 10a Next of Kin contact number. 80% 11 Is it documented that the parent/young person has been asked whether they 39% have an allergy? 12 If the child is on prescribed medication, is it recorded? 97% Chronology 13 Has the record keeping been completed with 24 hours of the date of the visit 85% / when the appointment took place? Accuracy 14 Is the record free from abbreviations? (other than those included in the approved list of abbreviations) 97% Relevant Clinical Information 15 Is the whole record visible on SystmOne? 86% 16 Does the record have a Universal referral? 98% 17 Electronic ledger used? 98% 18 Record of Action Plan and Outcome? 94% Error! No text of specified style in document. Findings 7 of 19

8 Q Question Total 19 Name of the venue that the consultation took place in? 98% 20 Compliance of breast-feeding box 10 days and 6-8 weeks? 93% 21 Evidence of transfer of care? 91% 22 Completed groups and relationships on the child s record? 95% 23 Evidence that body maps have been used correctly? 98% 24 Evidence that the growth chart was used? 99% 25 Is the journal free from third party information? 97% Evidence of Service User involvement 26 Has the service user given consent to share? 98% 27 Is there evidence that interpreters have been used, where necessary? 88% Safeguarding 28 Has the latest case conference and core group been recorded? 100% 29 Is there evidence of safeguarding supervision recorded in the case notes? 96% SystmOne 30 Are the last five Health Visitor tasks free from clinical information? 89% 31 There is evidence that needs and risk identified during the assessment process 100% are reflected in the care? 32 There is evidence that interventions in the care plan are implemented in practice? 98% Overall Compliance 93% SCHOOL NURSING Service User Demographics Q Question Total 1 Full name 98% 2 NHS Number 100% 3 Electronic record has been matched to the NHS Spine 99% 4 Address, including postcode 100% 5 Gender 100% 6 Date of Birth 100% 7 Telephone number 85% 8 GP Name 86% 8a GP Address 79% 9 Ethnicity 60% 10 Next of Kin contact name 54% 10a Next of Kin contact number 47% 11 Is it documented that the parent/young person has been asked whether they 28% have an allergy? 12 If the child is on prescribed medication, is it recorded? 81% Chronology 13 Has the record keeping been completed with 24 hours of the date of the visit 81% / when the appointment took place? Accuracy 8 of 19 Findings Error! No text of specified style in document.

9 Q Question Total 14 Is the record free from abbreviations? (other than those included in the approved list of abbreviations) 87% Relevant Clinical Information 15 Is the whole record visible on SystmOne? 89% 16 Does the record have a Universal referral? 94% 17 Electronic ledger used? 67% 18 Record of Action Plan and Outcome? 89% 19 Name of the venue that the consultation took place in? 91% 20 Evidence of transfer of care? 79% 21 Has the School Nursing Team completed groups and relationships on the 54% child s record? 22 Evidence that body maps have been used correctly? 53% 23 Evidence that the growth chart was used? 87% 24 Is the journal free from third party information? 96% Evidence of Service User involvement 25 Has the service user given consent? 97% 26 Is there evidence that interpreters have been used, where necessary? 100% Safeguarding 27 Has the latest case conference and core group been recorded? 85% 28 Is there evidence of safeguarding supervision recorded in the case notes? 79% SystmOne 30 Are the last five School Nursing tasks free from clinical information? 87% 31 There is evidence that needs and risk identified during the assessment process 87% are reflected in the care? 32 There is evidence that interventions in the care plan are implemented in practice? 88% Overall compliance 82% Comments The compliance rate for Health Visiting Service is 93% The compliance rate of School Nursing Service is 82% The overall compliance rate for the Health Visiting & School Nursing Service is 88% Health Visiting School Nursing Overall Compliance Service User Demographics 91% 80% 85% Chronological Order 85% 81% 83% Accuracy 97% 87% 92% Relevant Clinical Information 95% 80% 87% Service User Involvement 93% 98% 95% Safeguarding 98% 82% 90% SystmOne 96% 87% 91% Error! No text of specified style in document. Comments 9 of 19

10 From the seven sections of the re- audit, four of the sections scored a compliance of acceptable and three sections were partially acceptable. There has been an overall 11% compliance rate improvement in all sections. School Nursing, with an overall compliance rate of 82% showed a slightly lower compliance rate that Health Visiting, with an overall compliance rate of 93%. Questions 1 6: Name, NHS Number, Electronic record matched to NHS spine, Address including Postcode, Gender, Date of Birth. The compliance rates in both Health Visiting and School Nursing on these first seven criteria were all acceptable, with the majority scoring 100% compliance which is extremely positive. Question 7: Telephone number: The compliance rate for the recording of telephone number was acceptable in Health Visiting and partially acceptable in School Nursing records. The School Nursing Service would ensure that the young person s phone number is recorded where they utilise the SMS messaging service. Question 8 and 8a: Recording of GP Name and address The recording of GP name and address were acceptable in Health Visiting records, and partially acceptable in School Nursing records. Following the recent re-alignment of Health Visitor caseloads in the City, it was noted that not all families are registered with a family GP, and this could explain the lower compliance rates. Question 9: Ethnicity The baseline audit results showed minimal compliance with the recording of ethnicity (69%). However, the re-audit can evidence marked improvement with recording of ethnicity within Health Visiting at 93%. For all babies born in Leicestershire, UHL record the child s ethnicity on the patient record at source, however for all movements-in this is not recorded. There will be a natural increase in the compliance of recorded ethnicity as children move from Health Visiting caseloads to School Nursing. School Nursing recording of Ethnicity is currently 60% (minimal compliance). Question 10: Next of Kin Name and Contact Number: The baseline audit results showed minimal compliance with recording of Next of Kin contact information at 67%. Again, an improvement can be evidenced at the re-audit stage with partially acceptable levels of 80% compliance within the Health Visiting Service. In School Nursing, the compliance rate has fallen to a minimal compliance rate of 54% for name and 47% for contact number. The School Nursing Professional Lead has identified that it may be inappropriate or insensitive to the young person s needs to ask for a next of kin s name and contact detail, if they have attended an appointment, for example, for contraceptive advice or following an episode of self-harm. A natural increase in compliance rates will be seen as children move from Health Visiting caseloads to School Nursing. Question 11: Is it documented that the parent/young person has been asked whether they have an allergy: The baseline audit results showed minimal compliance of the allergy status of a patient being recorded. Across the three areas, the average compliance was 12%. Whilst the re-audit did show a slight increase in the compliance rate up to 39% in Health Visiting and 28% in School Nursing, concerns have been raised by the Professional Leads in both services regarding the appropriateness of the question at some contacts. 10 of 19 Comments Error! No text of specified style in document.

11 Within Health Visiting Service, if records of newborn babies were part of the audit sample, these would not have shown an allergy status recorded as newborn babies are not born with allergies, and rarely develop them until at least 2 years of age. With regard to School aged children, the question of a child s allergy status is not always appropriate to ask, if the young person wishes to consult their school nurse following an episode of self harm, or to seek advice on bullying, for example. Following the baseline audit, the action of adding the child s allergy status to the SystmOne template has been completed, and staff are demonstrating awareness of where to access this. The next record keeping audit will require a review of how this question is worded, ie included not applicable as an option. Question 12: If the child is on prescribed medication, is it recorded? A marked improvement in compliance has been evident in this re-audit. Health Visiting Service demonstrates an acceptable compliance at 97% and School Nursing a partially acceptable result of 81%. The baseline audit figure was 27%, so this level of improvement is very encouraging and will benefit patient care. Question 13: Has the record keeping been completed within 24 hours of the date of the visit/appointment. Both Services demonstrate partially acceptable results (85% for Health Visiting and 81% for School Nursing), which again shows a marked improvement over the baseline audit results of 59%. The LPT Record Keeping Policy requires all clinical inputting to be carried out contemporaneously, within 24 hours of the visit, and there is still room for improvement within both Services to achieve acceptable compliance. Question 14: Is the record free from abbreviations? The Trust-approved Abbreviations List was issued in June 2014, Health Visiting Service demonstrate acceptable compliance levels of 97% and School Nursing partially acceptable levels at 87%. The audit would be carried out on the whole patient record, therefore increased compliance rates will only be evident on newer records. Question 15: Is the whole record visible on SystmOne? For both Health Visiting and School Nursing the results for this were partially acceptable at 86% and 89% respectively. Since the introducing of the EDSM sharing model in March 2014, explicit consent or dissent to share clinical information is now obtained from the individual. There are some occasions where consent is not given (explicit dissent), and therefore the whole record would not be visible due to patient choice. Question 16: Does the record have a Universal referral? Both Health Visiting & School Nursing have historically recorded referrals well, this re-audit continues to show acceptable results at 98% and 94% respectively. Question 17: Has the electronic ledger been used? Health Visitors use of the electronic ledger demonstrates very good compliance levels, with results being acceptable at 98%. School Nurses use of the electronic ledger has shown minimal compliance at 67%. Further work is required by Clinical Team Leaders to monitor the use of paper diaries, and the Action Plan will reflect the work which will need to be carried out in this area. A Task & Finish Group has been set up Error! No text of specified style in document. Comments 11 of 19

12 by the FYPC Clinical Lead for IT to carry out a scoping exercise on the use of paper diaries and compliance with Policy. Question 18: Record of Action Plan and Outcome Health Visitors have recorded the Action Plan and Outcome in 94% of the audit sample, which shows acceptable compliance. School Nursing falls slightly below this at 89% which is partially acceptable. Continued work is required to increase compliance levels in this area. Question 19: Name of venue that the consultation took place in: Both Health Visiting and School Nursing compliance rates are acceptable, at 91% and 98% respectively. Question 20: (Health Visiting) Compliance with breastfeeding box 10 days and 6-8 weeks. Health Visiting results were acceptable at 93%. The Infant Feeding Co-Ordinator continues to provide quarterly reports to Clinical Team Leaders to identify those records with missing breastfeeding status data and these are completed retrospectively, where possible. There are occasions where families are, for example, out of the UK at the time of the development review, so the data would be missing from these records. Question 20/21: Evidence of Transfer of Care: Health Visiting results were acceptable at 91% compliance. School Nursing rates were 79% compliant which are partially acceptable. Bulk transfers of Health Visiting to School Nursing caseloads would occur routinely every summer. It should be questioned what element of transfer of care is being audited (ie receiving caseloads from Health Visitor, or transfer of care to adult services?) within School Nursing. Question 21/22: Have Groups and Relationships been completed? Health Visiting results were acceptable at 95%. School Nursing results showed minimal compliance levels at 54%. Additional work will need to take place to ensure that all school nurses complete their own names in the young person s SystmOne record and the Action Plan will reflect this. Question 22/23: Evidence that body maps have been used correctly? Health Visiting results show a 98% compliance with the use of body maps. School Nursing results showed minimal compliance at 53%. Are Body maps utilised re self-harm in school-aged children? Question 23/24: Evidence that the growth chart has been used correctly? Health Visiting results showed acceptable compliance with the use of growth charts at 99%. At 87%, School Nursing results were partially acceptable. Question 24/25: Is the journal free from third party information? Both Health Visiting and School Nursing compliance rates were acceptable at 97% and 96% respectively. These results show excellent results. Question 25/26: Has the service-user given consent to share? 12 of 19 Comments Error! No text of specified style in document.

13 Both Health Visiting and School Nursing compliance rates were acceptable at 98% and 97% respectively. These results show excellent results. Question 26/27: Is there evidence that interpreters have been used, where necessary? Health Visiting compliance rates were partially acceptable at 88%. School Nursing achieved 100% compliance rates which is excellent. There is written evidence within electronic patient records to suggest that family members are informally used for interpreting during home visits, and this could explain the lower compliance rate for this Service. Question 27/28: Has the latest Case Conference and Core Group been recorded: Health Visiting achieved 100% compliance rates which is excellent. School Nursing compliance rates were partially acceptable at 85%. School Nurses may not always attend Case Conferences or Core Groups, if Health Visiting Services are involved with the family and are in attendance. An arrangement would be made between the Service to avoid duplication of information. Question 28/29: Is there evidence of Safeguarding Supervision recorded in the case notes? Health Visiting compliance rates were acceptable at 96% and School Nursing results were partially acceptable at 79%. Improvements are required within the School Nursing Service and the Action Plan reflects this. Question 29/30 Are the last five Health Visitor/School Nurse tasks free of clinical information? Improvements have been made in this area, with 89% and 87% compliance rates in Health Visiting and School Nursing respectively. There is still room for improvement, but it should be noted that some electronic records may only contain a minimal number of tasks (under 5 tasks) so the audit could still cover tasks of a significant age, prior to the communication regarding the omission of clinical information. Improvements should therefore be seen in future audits. Question 30/31: There is evidence that needs and risk identified during the assessment process are reflected in the care? Health Visiting rates showed 100% compliance in this area, which is excellent. School Nursing results showed partially acceptable results at 87%. Improvements should be made in this area and are reflected in the Action Plan. Question 31/32: There is evidence that interventions in the care plan are implemented in practice? Health Visiting compliance was acceptable at 98%. School Nursing compliance rates were partially acceptable at 88%. Again, improvements should be made in this area and are reflected in the Action Plan. Error! No text of specified style in document. Comments 13 of 19

14 Recommendations See Appendix 3 on p.19 for the action plan. Recommendation 1: Recommendation 2: Recommendation 3: Recommendation 4: Recommendation 5: To reword the question is it documented that the parent/young person has been asked whether they have an allergy? as this is not always appropriate to ask at all types of consultation, ie bereavement. To ensure School Nurse compliance with the LPT Lone Worker Policy by recording all appointments in their electronic ledgers. School Nurses to complete Groups & Relationships in all cases, to include their own name and that of the young person s next of kin (including contact phone number). Body maps to be completed by School Nursing Service where appropriate. Create a poster display at all bases providing audit results feedback to Health Visiting and School Nursing staff members. References None. 14 of 19 Recommendations Error! No text of specified style in document.

15 Appendix 1 Audit tool 15 of 19 Error! No text of specified style in document. Audit tool

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17 Distribution list Error! No text of specified style in document. References 17 of 19

18 Target audience All School Nurses All Health Visitors To (for action) Name, designation Chris Buzzard, Service Manager, Health Visiting & School Nursing Maggie Clarke, Professional Lead, School Nursing. Chris Buzzard, Service Manager, Health Visiting & School Nursing Nicy Turney, Professional Lead, Health Visiting Cc (for info) Name, designation Kam Gill, Locality Manager Maureen Curley, Locality Manager Jane Sansom, Locality Manager Chris Davies, Locality Manager Teresa Farndon, Locality Manager Kam Gill, Locality Manager Maureen Curley, Locality Manager Jane Sansom, Locality Manager Chris Davies, Locality Manager Teresa Farndon, Locality Manager 18 of 19 References Error! No text of specified style in document.

19 Appendix 2 Action plan Objective To reword the question is it documented that the parent/young person has been asked whether they have an allergy? as this is not always appropriate to ask at all types of consultation, ie bereavement. Level of Risk L M H Medium Agreed Action By Whom By When Resources Required Reword audit question when designing next audit tool. Professional Leads Audit Officer Audit Tool 2016 To ensure School Nurse compliance with the LPT Lone Worker Policy by recording all appointments in their electronic ledgers. High To discuss Lone Worker Policy and use of electronic ledgers in team meetings. Locality Managers & Clinical Team Leaders (SN) Spot checks. School Nurses to complete Groups & Relationships in all cases, to include their own name and that of the young person s next of kin (including contact phone number). High To discuss correctly completing Groups & Relationships in team meetings. Locality Managers & Clinical Team Leaders (SN) Spot checks. Body maps to be completed by School Nursing Service where appropriate. Medium To discuss utilisation of body maps within SystmOne at team meetings. Locality Managers & Clinical Team Leaders (SN) Spot checks. Create a poster display at all bases providing audit results feedback to Health Visiting and School Nursing staff members. Low Create audit results poster and display at HV & SN team bases. Audit Team Time & Design Skills. Complete Error! No text of specified style in document. References 19 of 19