Record keeping

This short guidance from the RCN aims to clarify the issues of delegating record keeping and countersigning records for nursing staff and employers.

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.

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.

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.

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.

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.

This eBook provides a structured programme of support for nursing students and newly registered nurses. Chapter 6 covers record-keeping, care planning and clinical risk assessment tools.

This guidance sets the direction for all nursing documentation across hospitals, community and nursing homes. It is intended to help organisations implement record systems and policies which support nurses to produce good documentation that supports and evidences professional decision making and care, while minimising time spent on producing those records.

The PRSB work with people who use services, carers, nurses and other health professionals to define the information that is needed in a given situation when someone receives care. Their suite of standards tell providers what information should be recorded and shared and can work with any system in use locally.