The importance of good record-keeping for nurses

Abstract

Good record-keeping is a mark of the skilled and safe practitioner, yet allegations concerning shortcomings in nurses' record-keeping were the second most common category of hearing brought before the UKCC in 2000-2001. The absence of accurate records makes it difficult for practitioners to prove they provided appropriate care should they be asked to do so in a professional or legal hearing. This is particularly pertinent since litigation against health professionals is increasing rapidly. This article discusses the importance of keeping comprehensive and accurate records of patient care and decisions from the perspective of nurses, their patients and colleagues. It also discusses the elements of good record-keeping, as well as practices to avoid.