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Table 3 Final set of Intellectual Disability Nursing Process Metrics and Indicators

From: Development of nursing quality care process metrics and indicators for intellectual disability services: a literature review and modified Delphi consensus study

1. Nursing DocumentationNursing written records are legible, in permanent ink and signed
Documented alterations/corrections are as per NMBI Guidance
Personal information is stored securely with access only to relevant persons in order to protect the privacy and confidentially of the individual’s details
Documented entries are dated and timed (24 h clock)
Documented entries are in chronological order
Documented abbreviations/grading systems are from a national or local approved list/system
All student nurse documented entries are countersigned by the supervising nurse
2. Medicines ManagementAll medicinal products are stored in a locked cupboard/trolleys/or room
Misuse of Drugs Act (MDA) are checked & signed at each shift changeover by registered nursing staff (member of day & night staff)
Two signatures are entered in the MDA Drug Register for each administration of an MDA.
The MDA cupboard is locked and keys are held by the designated nurse
MDA drug keys are kept separate from other medication keys
The person’s prescription documentation provides details of person’s legible name, unique identifier and photo ID
The Allergy Status is clearly identifiable on the front page of the prescription chart
Prescribed medicines not administered have an omission code entered and appropriate action taken
The prescription start date is recorded
The correct legible dose of drug is recorded with correct use of abbreviations
The route and/or site of administration is recorded
The frequency of medicines administration is as prescribed
The minimum dose interval and/or 24 h maximum dose is specified for all PRN medicines
The prescription has the prescriber’s signature (in ink) and Medical Council Number/Nursing and Midwifery Board of Ireland personal identification number
Discontinued medicines are crossed off, dated and signed by person with prescriptive authority
All medicines are reviewed in accordance with medication protocols
A current Drug Formulary is available at the point of administration
The generic name is used for each medicine unless the prescriber indicates a branded medicine and states “do not substitute”
There is a support plan for self-administration of medication
Self-administration of medicines is monitored for compliance and safety
3. EnvironmentPolicies, Procedures, Protocols and Guidelines (PPPGs) are current and signed by each registered nurse
There is evidence of an action plan based upon the most recent regulatory inspection
Environmental and infection control audits have been conducted and relevant action plans are in place
4. SafeguardingSafeguarding policies are reviewed and up to date
Information is provided to the person regarding their rights (support to exercise their rights, advocacy, safeguarding/protection) in accessible formats
Where there is evidence of a safeguarding concern there is documentation of registered nurses compliance with the safe guarding policy
A personalised risk assessment has been carried out in consultation with the person and relevant persons (family, advocates and the multidisciplinary team) and evident in the nursing care plans
A plan is in place on the person’s personal property, finances and possessions
When assisting the person in the management of their finances, there is evidence that clear records are maintained, reconciled and subject to audit
5. Person centred communicationA communication assessment has been conducted and a plan is documented
The person’s choice is obtained, respected and documented
Communication strategies are identified in the persons care plan
The person’s communication level and style are documented
Non-verbal and atypical communication behavioural patterns are documented
There is documented evidence of a multidisciplinary team approach
Information provided is in an accessible format for the individual
Where non-engagement occurs, this is noted in the persons care plan
6. Physical health assessmentsA comprehensive health assessment has been conducted
Known associated health risk factors are identified within the care plan
A recognised assessment tool for persons with an intellectual disability has been used or appropriate tool adapted for specific areas e.g. pain, oral care, nutrition, hydration
The person has been supported to engage in health screening
The health care plan demonstrates a systematic approach to nursing care, management and interventions
Physical health checks are conducted at least annually
An individualised health passport has been developed in conjunction with the person
7. Mental health assessmentA nursing mental health assessment has been conducted and documented
A diagnosis of mental health illness is documented
The individuals care plan demonstrates the nursing care, management and interventions to support the person’s mental health and well-being
8. Risk assessment and managementThere is evidence of positive proactive risk assessment and an action plan for identified risks within the persons care plan
Appropriate referral and resulting consultations have occurred to address identified risks and are documented
Incidents are documented within the care plan and escalated/reported as appropriate
A risk re-assessment is conducted and documented
9. Nursing care planThe personal plan is based on a model of care (Nursing Care Plan is based on an identified model of care)
An assessment of need has been conducted and documented
An individualised plan of care has been developed
All documented nursing interventions are dated, timed and signed
The care plan reflects the persons’ current health needs
There is evidence of regular review of the care plan, dated, timed and signed
10. Person centred planningA personal plan/assessment of all aspects of the person’s life has been conducted
Actions/interventions are devised to support the person within their personal plan
There is evidence of the person’s involvement in their Personal Plan
The person’s level of need and preferences regarding the provision of intimate personal support are identified
Self-advocacy/choices are recorded, respected and documented
A transition plan exists across each life course stage
11. Positive behaviour supportAn assessment of distress has been conducted
A personal behavioural plan exists
Proactive and reactive behavioural strategies are identified and evident
There is evidence that positive behavioural support strategies are reviewed by the multidisciplinary team
12. End of life/palliative careAn end of life care plan is evident and documented
The person has been supported to make end of life decisions and this process is evident within the personal care plan
An ongoing assessment of changing health needs is evident and document
A collaborative approach is in evident across services
There is evidence of ongoing information sharing with the individual regarding their end of life