NHS England (NHSE) has released guidance on clear and accurate record keeping for nurses, with a focus on digitising documentation.

Good documentation is vital to supporting professional decision making and care in nursing and as the NHS increasingly moves to a digital-first approach,  it is crucial that the challenge of moving from traditional paper-based systems to digital ones is addressed.

In 2020, the digital nursing team at what was then NHSX worked with the Professional Records Standards Body (PRSB) to look at the feasibility of developing a national nursing documentation standard. The report’s recommendation was that the “standard should be interoperable and fully integrated into shared care records where the provenance and contextualisation of patient/citizen information is paramount for clinical safety”.

Now, NHSE has revealed a unified vision for producing good documentation with a standardised framework for nursing across health and social care systems in England, which ensures nursing practice is supported by digital technology.

The guidance – which was released last week – will help set the direction for standardising nursing documentation; reduce unwarranted variation in what is documented across organisations; proactively manage documentation; and support the use of technology in order to streamline the process and support effective decision making.

NHSE also sets out some basic principles for digital tools. This includes that they should facilitate intuitive data entry; support the ability for data to be entered once and reused where clinically appropriate and safe, in order to avoid repeat data entry; and support searching of the record.

In addition, it advises that clinical decision support tools should be used to support safe and effective decision making and to streamline documentation at the point of care.

NHSE also underlines how the digitisation of documentation by nurses can also support wider goals of extracting data. It notes that any digital system should visualise data in a way that allows registrants to see trends over a period of time. Additionally, it recommends tools that support data extraction from the care record and the use of business intelligence tools to support reporting, service evaluation, auditing and research. This would mean that no further clinical documentation would need to be completed to support audits or service evaluation.

Digital Health Rewired24’s conference programme will include a digital nursing stage, when it happens at The NEC in Birmingham on the 12-13 March, where the challenges facing nurses in a digital NHS will be discussed.