Link the recording of all information to the principle of person-centred care
If you went to Marks & Spencer to buy a T-shirt and when you got to the till and tried to pay they said: “Oh, we are not sure if this is £5.99 or £59.99!” I think you may be a bit concerned. You probably expect them, even if the label is missing, to be able to give you an accurate answer and fairly promptly. Yet I’m not sure in nursing we have got our heads around the same issue in relation to the data we record in the various systems that we work withto make decisions.
M&S makes it its businessto manage information and know its business; while I’m not advocating we operate like a retail business, there are some real lessons for us to learn; M&S knows the importance of data quality.
Data quality can be defined as data that is timely, complete, accurate, consistent and meaningful. We need to ensure the quality of our data when we record information about what we do.
We should be recording consistently, accuratelyand avoiding duplication.
We should take accountof the record keepingstandards from the Nursing and Midwifery Council (tinyurl.com/NMC-guidance-record-keeping).
Steps you can take to ensure high-quality data
● Make clear accurate record keeping part of your leadership focus
● Take steps to make sure your data and information is correct
● Understand the systems you use and how the information from them contributes to safe, quality care
● Know your information - understand what the information says about care
● Ask questions about the information you record
● Be aware that patients will soon have access to their records
Information we record should be attributable to the person recording it. If we record data in this way we will be creating reliable information that is fit foruse for many purposes. It will be information that we can trust.
In the health service we make decisions all the time based on information that comes from a variety of places and increasingly these are electronic systems.
We need information for clinical decision making,but also to work out the healthcare resources we need and how best to meet the needs of patients.
We must understand that even though we don’t necessarily see the relevance of an individual piece ofdata it could be used somewhere else to make a different sort of decision, maybe on issues surrounding financeor staff.
It is important to link the recording of data to the principle of person-centred care and, in the same way we see safe, quality care as important, see information as important too.
All information recorded should have a role otherwise why would we be recordingit? Where there may be a direct link to a task, for example ordering medications, we are aware of the importance of accuracy, but where there is a less clear link to a decision or outcome, data quality often does not seem to be taken seriously.
Anne Cooper is clinical informatics adviser (nursing) for NHS England. She was previously the national clinical lead for nursing at the Health and Social Care Information Centre. She started her career in cardiology and chest medicine. After working in IT for NHS Direct, she became fascinated by informatics