Safe record keeping in nursing practice

• Records support safe decisions, highlight risks early and help teams work together.
• Records provide evidence of care and may be used in audits, service reviews and legal processes.

• Standard: The NMC Code (Practice effectively, 10.3) states that registrants must “complete all records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements”.
• Timing: Records should be completed at the time or as soon as possible after care or the event.
• Traceability: All records must be signed, timed and dated if handwritten. If digital, they must be traceable to the person who provided the care.
• Systems: Ensure that you are up to date on the use of electronic systems in your place of work, including security, confidentiality, GDPR requirements and appropriate usage.
• Accuracy: Records must be completed accurately and be factually correct, without any falsification. They should provide information about the care given, as well as arrangements for future and ongoing care.
• Language: NMC guidance states that records should “not include unnecessary abbreviations, jargon or speculation”. Use professional judgement, rather than speculation, to make informed decisions. This is referenced in the NMC Caring with Confidence: The Code in Action animations.
• Involvement: When possible, the person in your care should be involved in record keeping and should be able to understand what the records say.
• Clarity: Records should be legible in original, copied and scanned formats. In the rare case of needing to alter a record, the original entry must remain visible and the new entry signed, timed and dated. If handwritten, use black ink.
• Security: Records must be stored securely and should only be destroyed following your local policy and GDPR guidelines.

• Record keeping can be delegated by registered nurses or midwives to nursing support workers. This includes all in support roles in nursing, such as health care assistants (HCAs), health care support workers (HCSW), assistant practitioners (APs), trainee nursing associates (TNAs), nursing associates (NAs), apprentices and students.
• The registered nurse or midwife must ensure that the person is competent and that it is in the patient or service user’s best interests.
• Supervision and countersignature are required until competence is demonstrated and supervision is no longer required.
• Registered nurses and midwives should only countersign an entry if they witnessed the care, or if local policy requires a countersignature while the other delegated person is still being supervised. In that case, the nurse should only countersign when they can confirm the person is competent (for example, via signed‑off competencies).

Additional guidance is available in The Code on the NMC website.

• NHS England is moving towards a standardised approach (PDF) to nursing documentation across care settings to improve safety and reduce variation.
• Similar work is underway across the devolved nations, with Wales standardising and digitising nursing documentation through national programmes, Northern Ireland using regional person-centred documentation standards alongside an integrated care record programme and Scotland supporting consistent record management and person-centred record design.
• Digital systems should let you enter data once, reuse it where clinically appropriate and safe (for example, by pulling through confirmed information rather than retyping it) and search records easily. Records should help you see trends over time and support care planning. Learn more by reading NHS England’s ‘What good looks like’ framework for digital health records.
• Where available, clinical decision support tools should support safe and effective decision making and help streamline documentation at the point of care.
• The same professional standards apply whether notes are paper or digital (PDF): accurate, timely, attributable and free of falsification.

• Records may be required for safeguarding enquiries, coroners’ inquests, serious incident reviews, NMC Fitness to Practise hearings and other investigations.
• Follow local information governance and data protection policies in every organisation where you work.

Download the Royal College of Midwives Electronic Record Keeping Guidance and Audit Tool (PDF).

• Use plain English, ensure records are factually correct. explain any necessary clinical terms and avoid acronyms.
• Keep entries person-centred; involve the person in their record where you can.
• If you are considering ‘copy and pasting’ in records, you must follow your employer’s policy and make sure entries remain accurate, clearly attributable to you, and are not falsified or misleading.
• If using templates or drop-downs, add free text where needed to capture clinical judgement.

• Digital Health (news summary of NHSE guidance). NHSE publishes guidance on digitising documentation for nurses.
• NHS England. Towards a unified vision of nursing and midwifery documentation (PDF).
• NHS England. Towards a unified vision of nursing and midwifery documentation.
• NHS Professionals. Record keeping guidelines.
• NMC: Standards (includes the Code).
• Northern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC). New Regional Standards for Person-centred Nursing and Midwifery Documentation.
• Royal College of Midwives. Electronic record keeping guidance and audit tool.
• RCN. Access the RCN’s record keeping reading list, which covers all four UK nations
• Scottish Social Services Council (SSSC). Codes of Practice.
• Scottish Government. Code of Practice for Employers of Healthcare Support Workers in Scotland.
• Scottish Government. Health and social care - records management: code of practice.