NHSE guidance on nursing and midwifery documentation sets out principles for “good” digital documentation

NHS England has published new guidance titled, “Towards a unified vision of nursing and midwifery documentation”, which “sets the direction for all nursing documentation across hospitals, community and nursing homes”.

The new guidance highlights the digitisation of the NHS in making visible “the volume of documentation that nurses are asked to produce, and the variation that exists, even within the same organisation”. It cites the challenges of moving from paper-based systems to digital ones, including cultural issues associated with reducing unwarranted variation and changing clinical practice. The guidance also claims that addressing these issues 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”.

The guidance moves on to 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. As well as covering the need for documentation to be fit for purpose and the requirement for organisations to have “appropriate central governance structures and controls in place to manage documentation”; it states that 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. In instances where dual paper and digital systems are in place, the guidance recommends a “standardised approach” to documentation which supports the same thing being documented in the same way.

On digital tools and usability, the guidance notes that 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. As such, system design for documentation must fulfil a number of characteristics, including facilitating intuitive data entry, supporting the avoidance of repeating data entry, supporting searching the record, enabling the person completing the documentation to be traced, and support data extraction from the care record and use of business intelligence tools to “support reporting, service evaluation, auditing and research”.

The new guidance is inspired by scoping work completed in 2019, which critically examined existing approaches to nursing records and began to identify possible new requirements. Key findings from this research included “a lack of understanding of what good documentation looks like in a digital context”, and “nurses struggling to see the art of the possible using digital technology, both in a general sense but also in relation to nursing documentation”.

In other newly-released guidance, NHSE also published guidance on point of care testing for virtual wards and urgent community response earlier this month.

NHSE guidance from August also focused on the procurement of technology to support virtual wards across integrated care systems, focusing on the approach to procurement along with developing virtual ward specifications.

To read the new guidance in full, please click here.