Documentation in Nursing
Accurate, timely, and comprehensive documentation is a legal and professional requirement. The NMC Code states that nurses must keep clear and accurate records. Good documentation supports continuity of care, protects patients, and provides evidence of the care given.
Principles of Good Documentation
- Factual — Record what actually happened, not opinions
- Accurate — Be precise and specific
- Timely — Complete records as soon as possible after care
- Clear — Use legible handwriting or clear typing
- Comprehensive — Include all relevant information
- Objective — Record facts, not assumptions
- Contemporaneous — Record at the time or as soon as possible after
What to Document
- Patient observations and vital signs
- Medication administration
- Care provided and interventions
- Patient assessments
- Communication with patients, families, and the team
- Referrals and handovers
- Incidents and adverse events
- Consent discussions
- Care plans and updates
- Discharge planning
The Data Protection Act 2018
The Data Protection Act 2018 (incorporating the UK GDPR) governs how personal data, including health records, is handled. Key principles include:
- Data must be processed lawfully, fairly, and transparently
- Data must be collected for specified, explicit purposes
- Data must be adequate, relevant, and not excessive
- Data must be accurate and kept up to date
- Data must not be kept longer than necessary
- Data must be kept securely
Incorrect Records
If you make an error in documentation:
- Draw a single line through the error (do not use correction fluid)
- Write "error" or "mistaken entry" and initial
- Add the correct information
- Date and sign the correction
- Never delete or destroy records
Electronic Records
Increasingly, records are electronic. Never share passwords, always log out when leaving a workstation, and only access records of patients you are directly involved in caring for. Unauthorised access to records is a breach of confidentiality and may result in disciplinary action.