LibGuides: Record keeping: Journal articles

Journal articles

This reading list covers record keeping journal articles. Some resources may only be available to RCN members and RCN programme participants.

Use the menu on the left hand side to view more pages within the reading list.

Allen D (2023) Clear, concise and correct: getting patient notes right, Nursing Standard, 38(1), pp. 19–22.
Patient records are a vital communication tool that help optimise safety. Find out how to ensure your notes are accurate and support your patients’ care.
Armstrong A (2020) Record keeping and prescribing, Journal of Prescribing Practice, 2(6), pp. 280–284.
This article looks at the importance of record keeping during the process of prescribing for the non-medical prescriber. It focuses on the professional and legal requirements, in particular in relation to prescribing medication for a patient, whether that consultation is face-to-face or remote.
Ashurst A (2017) Reflecting on the nurse’s role in record keeping, Nursing & Residential Care, 19(12), pp. 714–715.
Keeping an up-to-date record of a resident's health and wellbeing forms an essential part of providing the best possible person-centred care. This article discusses why this is so important and what care home staff should document on a daily basis.
Brooks N (2021) How to undertake effective record-keeping and documentation, Nursing Standard, 36(4), pp. 31–33.
This article explains the importance of record-keeping and documentation in nursing and healthcare, and outlines the principles for maintaining clear and accurate patient records.
Creighton L, Smart A, Devlin N and Blair J (2022) Professionalism in nursing 4: record keeping, consent and capacity, Nursing Times, 118(7), p. 54-57.
Record keeping is an essential part of a nurse's role and can have both ethical and legal implications; however, common errors and omissions persist. As well exploring good record keeping this article discusses patient consent and capacity.
Elliott N (2022) Get on top of your record-keeping skills, Nursing Standard, 37(2), pp.41-42.
Accurate record-keeping is a vital part of good communication in nursing and integral to safe and effective practice. The point is underlined by the Nursing and Midwifery Council (NMC) code of conduct, which states that to practise safely, nurses must keep clear and accurate records relevant to their practice.
Tingle J (2023) Facing the consequences of poor record keeping and communication, British Journal of Nursing, 32(3), pp.152-152.
John Tingle discusses some publications on good practice in record keeping and communication and how failures can result in complaints and litigation.