Record keeping

Creating and maintaining good records of care is fundamental to the provision of safe and effective nursing care. Nurses must be able to access as well as create and update care records in order to:

• provide a plan for the delivery of care
• ensure care delivery is coordinated
• demonstrate what care has been given
• provide a legal record of care (Brooks, 2021)

For these reasons it is important nurses produce records to a reasonable standard.

Nurses need an understanding not only of what to do to produce handwritten records, but also their responsibilities as they relate to electronic records. There is a requirement to access and produce good quality records, as well as to maintain the safety and security of records in order to promote and preserve patient confidentiality (Nursing and Midwifery Council, NMC, 2018). 

A record is defined as:

Nurses considering the need for the production of records should remember that 'if it is not written down it did not happen' (Benbow, 2011). This indicates to nurses the importance of maintaining good records of all of their undertakings so that they can prove they did something at a later date. 

Nurses are accountable for their actions (Ellis and Ellis, 2021). This means they need to be in a position to give an account and provide a record of what they have done and why, when asked by, for example, their manager, the Care Quality Commission, the Nursing and Midwifery Council or the coroner. If the nurse has provided care they should record having done so because it protects them from accusations of neglect or worse.

Where the nurse is uncertain as to whether to record an action or activity, they might consider the adage 'if in doubt, write it

The equipment needed for creating a record will greatly depend on the nature of the record and the medium in which the record is being created. Written records must be legible and photocopiable. In general terms this means created using black ink which photocopies much easier than blue or other colours and never maintaining care records using pencil which can be erased (Stevens and Pickering, 2010).

As a rule nurses will need to select the right form or continuation sheet. prior to making a paper entry into a care record. Similarly, the nurse will need to identify the right place within any electronic records to make their entry. Again this is subject to local practice highlighting the importance of nurses engaging with local training.  

The nurse that they should complete any records as soon after the event as possible. This is also known as contemporaneous record keeping and is important as the nurse’s memory of events will change over time. Contemporaneous records are also important if the nurse ever has to justify their actions or prove something, e.g. in a court of law as they are widely seen as a good representation of what happened at a particular time. For paper records especially, this means nurses should date and time the entry using the 24-hour clock, e.g. 14.00hrs to avoid ambiguity.

All records kept by nurses should be factual and not speculative and increasingly nurses are reminded not to use jargon, but to write in a way which is understandable to other people who are not nurses. As well as being factual and understandable, it is important handwritten records are legible. Other staff accessing

As well as failing to record care given, poor quality record keeping and management risks the nurse compromising the privacy and confidentiality of patients, especially where electronic records are concerned.

Prideaux (2011) identifies how poor record keeping by nurses is associated with poor quality nursing care. It is therefore not acceptable for nurses to produce poor quality records as these may have a detrimental impact of the welfare of patients, e.g. illegible or missing records compromising the continuity of care. 

Nurses need to therefore ensure they undertake record keeping as part of their care routine rather than relegating it to the end of the day because they:

• have other priorities
• are too busy
• don not understand the necessity (Stevens and Pickering, 2010)

Nurses should ensure they understand their obligations with relation to accessing, creating, adding to and keeping safe patient records. They can do this by reflecting on guidance such as this article, in addition to local polices and procedures. Nurses who are new to a work place or need to refresh their understanding of record keeping would be well advised to attend a training session about record keeping within their place of work.

References

Benbow M. Documentation: Keeping Accurate Patient Records. Wound Essentials. 2011; 6:90-92.

Brooks N. How to undertake effective record-keeping and documentation. Nurs Standard. 2021. https://doi.org/10.7748/ns.2021.e11700

Grayer J, Baxter J, Blackburn L et al. Communication, psychological wellbeing and safeguarding in Lister S, Hofland J, Grafton H and Wilson C (eds.). The Royal Marsden Manual of Clinical Nursing Procedures (10th edn). Chichester: Wiley Blackwell; 2021 pp. 133-204

NHS Transformation. Records Management Code of Practice 2021. 2021. https://www.nhsx.nhs.uk/information-governance/guidance/records-management-code/records-management-code-of-practice-2021/ (accessed 9 January 2023)

Nursing and Midwifery Council. The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. 2018. https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf (accessed 9 January 2023)

Prideaux A. Issues in nursing documentation and record-keeping practice. Br J Nurs. 2011;20(22):1450-4. https://doi.org/10.12968/bjon.2011.20.22.1450

Stevens S, Pickering D. Keeping good nursing records: a guide. Community Eye Health. 2010;23(74):44-45.

Trenoweth S, Allymamod W.  Communication and Interpersonal Skills in Challenging Circumstances in In: Delves-Yates (ed.) Essentials of Nursing Practice.