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NHS Wales Nursing Documentation


A national programme is underway to transform the documentation nurses are required to complete. The Nursing Informatics leads in NHS Wales are coordinating a standardisation of nursing documents whilst Digital Health and Care Wales (DHCW) is working with clinical colleagues to produce digital nursing documents that follow a patient through their healthcare journey. The same standardised nursing language is being used to reduce duplication, to improve patient experience and outcomes of care.

Clinical representatives from every health board and trust in Wales are leading the standardisation and digitisation of nursing documents to ensure they are fit for purpose, patient focused and align to nursing process.

The following documents have now been developed and standardised and officially approved through the governance process for use across the NHS in Wales:

All Wales Document

Data Standards Specification

Adult Inpatient Assessment (AIA) AIA Specification
Patient Care Assessment in COVID-19 Emergency N/A
Adult Nutritional Risk Screening Tool (WAASP) Nutrition Specification
Continence / Toileting Risk Assessment Tool Continence Specification
Falls & Bone Health Multifactorial Assessment Falls Specification
Pain Risk Assessment Pain Specification
Patient Handling Assessment & Safer Handling Plan Patient Handling Specification
Purpose T Pressure Ulcer Risk Assessment Purpose T Specification
Bowel Assessment Chart  Bowel Assessment Chart Specification
Repositioning Chart Repositioning Chart Specification
Mouthcare Assessment Mouthcare Assessment Specification


If there is anyone looking to develop a new document / standard nationally please refer to the SOP - National Information Data Standardisation.