Follow us
Log in
Much of the content on our site is available to our registered users only. If you're already registered, just click the 'Log in' button then enter your email address and password.
Register
If you're not already registered on the site, you'll need to do so in order to gain unrestricted access to all our content. There are two types of registration:
1. If you're a current subscriber, you can register for access to our protected content at no additional cost. You'll need your subscription number in order to complete your registration, which is on the polythene wrapper in which your journal is delivered. Click the Register button to begin your registration.
2. If you don't currently subscribe you can do so now by taking out a secure online subscription. Not only will this give you instant access to our protected online content, but you'll also get every issue of Nursing Standard - the UK's best selling nursing journal - delivered straight to your door. Click the Register button to begin your subscription and registration.
Put it down on paper
Clear, concise record-keeping is a vital part of good patient care, explains Jane Redfern Jones
Patient records are kept for three reasons - as a diary of the patient's journey, as a means of communication between those involved in the patient's care and as evidence in the event of a complaint or investigation into standards of care.
Anything written in relation to your work as an employee becomes a public record and under the Data Protection Act 1998, patients can apply to see what has been written about them. In deciding what and how much to write in a patient's record, a guide is to ask yourself: if I were caring for this patient for the first time, what would I need to know?
Write meaningful statements: comments such as 'patient slept well' or 'as per care plan' are not helpful. Also avoid vague phrases such as 'appears unsteady' - either the patient is or is not unsteady.
Do not mistake assumption for fact. For example, rather than 'the patient fell over', write: 'I found the patient on the floor in a position consistent with a fall'.
As a rule, abbreviations should be avoided. A number of universally accepted everyday medical abbreviations are used appropriately and safely, such as BP (blood pressure) and HR (heart rate). Writing these in full each time would considerably increase the time taken to complete records.
The key principles for quality record-keeping are outlined in the 2009 Nursing and Midwifery Council (NMC) guidelines. Although these were aimed at registered nurses, much of the information applies to all contributors to patient records.
Although record-keeping can be viewed as a chore that gets in the way of looking after a patient, you must allocate time for hands-on care and documentation because the two together constitute total and quality patient care.
Good record-keeping can be summed up by saying that anything you write must be honest, accurate and non-offensive and must not breach patient confidentiality.
Follow these rules and your contribution will be of value.
Essential checklist for writing a patient record
- Record events clearly and accurately.
- Write legibly and key in accurately on a computer.
- Date and sign all entries and obtain a countersignature if it is local policy
- Avoid abbreviations and vague comments.
- Record how a patient is contributing to their care.
- Cross out alterations with one line and date and sign the change.
- Never write insulting or derogatory comments.
- Write in black ink for legibility of photocopies.
Mentorship
.jpg)
Mentorship enables student nurses to apply their theoretical knowledge and put it into practice in a clinical situation.
Working abroad
Read and learn from others' experience of working in different countries.
The RCN Publishing Company is a wholly owned subsidiary of the Royal College of Nursing, the world's largest organisation for nurses. RCN Publishing produces one weekly, eight monthly and two quarterly nursing publications. Nursing Standard, the flagship journal, is the UK's biggest selling weekly for nursing. It is produced by RCN Publishing Company along with a suite of specialist nursing journals - Cancer Nursing Practice, Mental Health Practice, Learning Disability Practice, Nursing Children and Young People, Nursing Management, Emergency Nurse, Nursing Older People, Nurse Researcher and Primary Health Care. RCN Publishing Company also produce the RCN Bulletin, a major source of up-to-the-minute information for RCN members in all specialities, grades and working environments. With the latest nurse vacancies from trusts nationwide, it has become the most cost-effective nurse recruitment magazine available.