Paper records are out as South Pembrokeshire and Withybush hospitals become the first in Wales to document their nursing care on a new digitally-based record.
The Hywel Dda University Health Board says the current practice of recording and keeping paper records has become a burden, and is taking frontline staff away from care activities.
So it launched the Welsh Nursing Care Record (WNCR) earlier this year using the latest tablet-based technology to document nursing entries and risk assessments.
The health board is also working with other organisations to produce digital nursing documents that follows patients through their healthcare journey, using the same standardised nursing language to reduce duplication and improve patient experience and care.
Angharad Murray, staff nurse at Withybush Hospital said: “The new system has changed how I work and I found it so easy to learn how to use it. It’s a very efficient process with nursing notes now all in one place and I don’t have to decipher different handwriting styles anymore!”
Clinical representatives are leading the project to ensure it is fit for purpose. As a starting point, the teams have identified that the first set of documents to be standardised and developed digitally are the adult inpatient assessment and core risk assessments in relation to falls, pressure damage, pain, continence, nutrition, manual handling and discharge.
These have been chosen based on frequency of use, and those that have the biggest potential to improve patient assessment, inform care planning and enhance patient safety and outcomes.
Mandy Rayani, director of nursing, quality and patient experience said: “We are very excited to be involved in this collaborative project and to have the opportunity to influence the future of e-nursing for the benefit of nursing staff and patients.
“I’m proud of how nursing staff within Hywel Dda UHB have embraced this new way of working and we look forward to rolling it out to other hospital sites over the coming months.”
Claire Bevan, from the WNCR project and Fran Beadle, from Digital Health and Care Wales both said the project was running well so far and they hoped for it to continue and expand in the future.