The project team at Digital Health and Care Wales (DHCW) worked closely with Clinical Informaticists and multi-disciplinary groups to standardise and digitise core nursing documentation and risk assessments and develop an application that met the needs of nursing across Wales.

The project aimed to: develop and implement an integrated digital platform to support standardised nursing documentation across all patient populations; improve patient safety and reduce harm by providing clinical decision support at the point of assessment and documentation; increase efficiencies and improve outcomes in the management of patients by improvement of documentation, in line with recommendations by Healthcare Inspectorate Wales, 2014, Healthcare Inspectorate Wales, 2013, Trusted to Care (2014) and internal organisations audits ,and automate secondary audit data collection based on guidelines determined by NHS Wales nursing leadership and Welsh Government. Since 19th April 2021, five health boards and trusts in Wales are live with WNCR: Hywel Dda, Velindre, Swansea Bay, Powys and Cwm Taf Morgannwg.

The key achievements include nationally standardised nursing language and evidence-based multidisciplinary risk assessments across NHS Wales; iIncreased collaboration across Wales from health boards and multidisciplinary specialties nationally supporting evidenced based care; increased compliance and timeliness of documentation and risk assessment completion, increasing patient safety due to real time identification of risk and improved communication of patient care to wider multidisciplinary team Improved ownership of documentation by nursing staff. It also achieved simplified and reduced duplication of documentation increasing nursing satisfaction by minimising repetitive questioning and workload. Increased patient centred questions; improved audits and reduction in time spent manually auditing and increased adoption of technology by nursing based on user centred design. Reduction of paper documentation and costs of paper.