NMAHP record keeping guideline (G136)

Documentation is the record of care that is planned and delivered to patients by qualified registered practitioners or other caregivers under the direction of a qualified registered practitioner.

Record keeping is an integral part of professional nursing practice and influences the nursing care process. The quality of record keeping is a reflection of the standard of individual professional practice. Good record keeping is a sign of a safe and skilled practitioner. The principles of good record keeping in nursing care are well established and should reflect the person centred care core values that care is coordinated, care is enabling and care is personalised.

Allied Health Professionals (AHPs) are required to follow the record keeping standards outlined by The Health and Care Professions Council. AHPs have a professional responsibility to keep full, clear, and accurate records to safeguard continuity of care by providing information to colleagues involved in care and treatment. This is also required to ensure service users receive appropriate treatment that is in their best interests and to meet legal requirements or respond to Freedom of Information or Subject Access Requests; and evidence decision-making processes if later queried or investigated.

Accurate documentation is essential to maintain continuity and inform health professionals of ongoing care and treatment. It is not only a legal requirement but also provides legal evidence.

The Data Protection Act 1998 defines a health record as ‘consisting of information about the physical or mental health or condition of an identifiable individual made by or on behalf of a health professional with the care of that individual’

Good record keeping helps to protect the welfare of patients in our care by promoting;

• High standards of care.
• Accountability.
• Continuity of care.
• Better communication and dissemination of information between members of the multi-disciplinary team and patients.
• An accurate account of treatment, care planning and care delivery.
• The ability to detect changes to a patients’ condition and respond appropriately and timely to deliver high standards of care.

Good record keeping helps to protect the welfare of staff by;

• Demonstrating how decisions are made.
• Providing documented evidence of services delivered.
• Facilitating the management of complaints or legal process.
• Support Quality Improvement, Quality Assurance, Audits and Research.

The principles of good documentation and strict confidentiality apply to all types of records, regardless of how they are held. These include;

• Handwritten clinical notes.
• Digital documents.
• Electronic systems.
• Emails.
• Letters to and from other health professionals.
• Laboratory reports/results.
• Imaging – CT, MRI, X-Ray etc.
• Print outs from monitoring equipment.
• Incident reports and statements.
• Photographs and videos.
• Recording of conversations.
• Dicta-phone recordings.

All health records are legal, confidential documents. The Nursing and Midwifery Council (NMC) state that nursing staff are responsible for keeping accurate records and ensuring professional guidelines for records and record keeping are followed. All records should be constructed and completed in such a manner as to facilitate the monitoring of standards, audits, quality assurance and the investigation of complaints.

The Health & Care Professions Council (HCPC) Professional Standards of conduct, performance and ethics state;

• You must keep full, clear, and accurate records for everyone you care for, treat or provide other services to (10.1)
• You must complete all records promptly and as soon as possible after providing care, treatment or other services (10.2)
• You must keep records secure by protecting them from loss, damage or inappropriate access (10.3)

It is documented in the Nursing Times that nurses are subject to increasing scrutiny regarding their record keeping. Legislation such as the Human Rights Act 1998 and the Data Protection Act 1998 has increased the profile of and access to health records and patients are now more likely to complain about their care. As a result, it is important that nurses, midwives and allied health professionals keep up to date with legal requirements and best practice. Both the NMC Code of Professional Conduct and Health and Care Professions Council( HCPC) have documented that notes should be written up as soon as possible after the event and by law within 24 hours and free from jargon and meaningless phrases (for example slept well) and adheres to NHS AAA Equality, Diversity and Human Rights Policy.

HCPC provides excellent guidance for practitioners on their website as to the expectations for AHP record keeping with FAQs and a webinar session for practical advice and educational support.

A patient’s documentation should provide a clear and concise account of the treatment and care given and allows for good communication between the MDT.

Depending on the setting and type of record there will be variation in specific content and style, however broadly this should demonstrate;

• Name and hospital number on every page/screen, preferably a printed addressograph label on all paper sheets.
• Clear attribution of entries made in any paper or electronic records to the author, making sure they are clearly written, dated and timed (24hr clock)
• Do not include any unnecessary abbreviations as these can have a double meaning. Abbreviations can be used only if full word documented beforehand.
• Do not use jargon or speculations (for example patient slept well)
• In hand written records a signature should be followed by the author’s name in clear print as well as professional designation.
• All entries should be written or printed in indelible black ink.
• Corrections must show the date and time of the correction and if hand written should be crossed out by a single line and be clearly signed by the author. It must be clear what was written and why it was changed, no correction fluid/roll on to be used.
• In handwritten entries, space to the end of the line should be blocked off and do not leave spaces between paragraphs.
• Entries made by students must be countersigned by a supervising registered practitioner.
• Records should be written as soon as possible following the event and in chronological order, legally within 24hrs of the event.
• Each record should be factual, consistent and accurate.
• Notes should not be written in retrospect but if required to be written in retrospect must be clearly documented as such.
• Authenticated, the information is truthful and nothing extra has been added (for example a patient may have told you something in confidence and you are writing it for all to see)
• Clinical records should include
  • relevant clinical findings
  • the decisions made and actions agreed and by whom
  • the information that has been given to patients and relatives
  • investigations, treatments including drugs that have been prescribed.

AHPs should follow the Standards of Proficiency outlined by the HCPC however, the way in which you demonstrate you meet these standards will depend on your profession, job role, local policies, and guidance issued by professional membership and other bodies.

You must make informed and reasonable decisions about your records, which are in accordance with the law and our standards. If asked, you must also be prepared to explain the record keeping decisions you have made.

• In a court of law ‘if it has not been recorded, it has not been done’
• Documentation that includes patient identifiable data should be stored safely to ensure confidentiality.
• Any documentation containing patient identifiable data attached to emails should only be sent to and from an ‘NHS net’ email address.
• Personal information about patients held by health professionals is subject to a legal duty of confidence.
• The content of documentation should include information that allows the reader to fully understand the events that have occurred and be able to comprehend the care delivered.
• Adhere to your registered body with regards to patient confidentiality.
• Adhere to NHS AAA Health Records Management Policy for accessing health records.
• Patient’s records should be stored out of sight from members of the public and should not be left unattended at any time.
• Demonstrate that where necessary local guidelines relating to risk management have been followed and critical incidents reported.
• Infusion charts have equipment type and serial number clearly documented.

• Record keeping can be delegated to students to document their care.
• However, the registered practitioner must deem the student competent to undertake the task and that it is in the patients best interest.
• Supervision and a countersignature is required depending on your profession and governing body.
• Only countersign if the information documented is accurate or activity is witnessed or you can validate that it took place.

Digital documentation must follow the same principles which apply to paper documentation with added attention to security;

• Laptops and computers must be password protected to ensure the user can be identified.
• Do not share usernames or passwords with anyone.
• Do not leave electronic systems open.
• Laptops are encrypted and verification of the encryption process is required by NHS AAA for data protection.
• Entries electronically to documentation are locked and cannot be altered.
• Take reasonable measures to ensure a secure network.

Audit play a vital role in ensuring the quality of care that is delivered, as it identifies areas for improvement and staff development. Therefore every health care provider must ensure;

• Records are audited using a record keeping tool.
• Audit cycles and formats are agreed by profession and assurance is reported through appropriate governance structures.
• Evidence that action and learning has been taken as a result of the audit that occurred.

All health records are legal, confidential documents. It is not only a legal requirement to keep accurate records but also provides legal evidence of care given. In a court of law if it is not recorded, it has not been done.

Good record keeping helps to protect the welfare of patients in our care of any age by;

• Promoting high standards of care.
• Accountability.
• Continuity of Care.
• Better communication.

Good records should have;

• Accurate information.
• Demonstrate chronology of events.
• Show practice follows evidence based guidance.
• Show that local guidelines have been followed.
• Any critical incidents are reported.

Royal College of Nursing (RCN), Record Keeping (2023)

Health and Care Professions Council (HCPC) Record Keeping Standards (2021)

Nursing & Midwifery Council (NMC) Professional Code of Conduct (2015)
Read The Code online 

Health and Care Professions Council. Our expectations for your record keeping

The Nursing Times. The importance of good record keeping for nurses (2003)

Nursing & Midwifery Council. Record keeping: guidance for nurses and midwives

NHS Professionals. Record keeping guidelines. CG2

General Medical Council (GMC) – Good Medical Practice

The Medical Defence Union – Effective record keeping

Nursing and Midwifery Council. The code: Professional standards of practice and behaviour for nurses, midwives and Nursing Associates. 

Data Protection Act 2018. 

Human Rights Act 1998.

NHS AAA Health Records Management Policy
NHS AAA Equality, Diversity and Human Rights Policy