How to undertake effective record-keeping and documentation

Abstract

Why you should read this article:

• • To familiarise yourself with the importance of keeping clear and accurate patient records
• • To understand the approach for writing clear records that are free of jargon and speculation
• • To learn about patients’ rights in relation to accessing their medical records

Rationale and key points

Effective record-keeping and documentation is an essential element of all healthcare professionals’ roles, including nurses, and can support the provision of safe, high-quality patient care. 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.

• • Nurses’ regulatory standards for practice emphasise the importance of maintaining clear and accurate patient records.

• • Patient records provide evidence of the assessments and interventions that have been undertaken. They can facilitate continuity of care by enabling other healthcare professionals to clearly see patients’ current care plans and treatments.

• • The policies and procedures for maintaining patient records can vary between healthcare organisations, so it is important for nurses to check these and practice in accordance with them.

Reflective activity

‘How to’ articles can help to update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of:

• • How this article might enhance your practice, in terms of effective record-keeping and documentation.

• • How you can use the information in this article to educate nursing students and colleagues on the importance and principles of effective record-keeping and documentation.