Tag
Clinical Records
Recommendations related to clinical records
4 recommendations
100% accepted
Tag overview
Government Response
Recommendations in This Theme
recommendation across 1 inquiry
Across 1 inquiry
Tagged Recommendations
Recording Changes in Accountability
Any change in clinical accountability should be recorded in the notes.
- HSC Trusts reported that nurse-to-patient ratios on paediatric wards have been reviewed in line with professional standards (IHRD Implementation Programme, Department of Health NI, …
HSC Trusts
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.
- HSC Trusts reported that arrangements for parent and carer involvement in clinical decision-making have been formalised (IHRD Implementation Programme, Department of Health NI, March …
HSC Trusts
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.
- HSC Trusts reported that clinical audit programmes for paediatric care have been strengthened (IHRD Implementation Programme, Department of Health NI, March 2018). - No …
HSC Trusts
Record Keeping Audit
Record keeping should be subject to rigorous, routine and regular audit.
- HSC Trusts reported that arrangements for transfer of children between hospitals have been formalised with standardised protocols (IHRD Implementation Programme, Department of Health NI, …
HSC Trusts