2. It is a collection of recorded facts concerning a particular patient which contains sufficient information to identify the patient clearly, to justify diagnosis and treatment and to document results accurately.

3. It is a business record and as such is admissible into appropriate courts.

4. It is an official document.

5. A physical property of the hospital. The hospital is an official repository of the medical record.

7. An accurate assessment of the person’s physical, psychological and social well-being, and, whenever necessary, the views and observations of family members in relation to that assessment.

8. Evidence in relation to the planning and provision of nursing care.

9. An evaluation of the effectiveness, or otherwise, of the nursing care provided.

10. To facilitate communication between the patient, the family and all members of the healthcare team.

11. To provide documentary evidence of the delivery of quality patient care. The nursing record provides substantiation of practice for:

12. Continuity of care between health professionals

13. Debriefing of patients

14. Dealing with complaints

15. Nurses’ decision-making

16. Reflecting on and evaluating practice

17. Research of nursing practice

18. Documenting Consent to Treatment

19. Records should be used to document discussions and interactions with patients/clients about planning care. Consent to nursing care should never be presumed.

20. Where a suggested procedure carries with it any significant risk, the explanation of this should be documented in the patient’s/client’s notes.

21. Any information or advice given to a patient about the possible consequences of such a refusal should also be documented.

22. Guidelines for Good Practice in Recording Clinical Practice

23. The quality of nurse’s record keeping should be such that continuity of care for a patient/client/family is always supported.

24. At a minimum, a patient record should include the following:

25. * An accurate assessment of the patient’s physical, psychological and social well-being, and, whenever necessary, the views and observations of family members in relation to that assessment.

26. * Evidence in relation to the planning and provision of nursing care.

27. * An evaluation of the effectiveness, or otherwise, of the nursing care provided.

28. Narrative notes should be written frequently enough to give a picture of the patient’s condition and care to anyone reading them. They should provide a record against which improvement, maintenance or deterioration in the patient’s condition may be judged.

29. All health care staff should be encouraged to read each other’s entries in the record as this facilitates good communication between health care staff.

30. All narrative notes must be individualized, accurate, up-to-date, factual and unambiguous.

31. All written records must be legible.

32. It is the writer’s responsibility to ensure that the writing in a record is clear and legible. Handwriting that is difficult to read should be in print form. Care should be taken to ensure that the record is permanent and facilitates photocopying if required. Pencil should never be used, as it can be altered or erased.

33. All entries must be signed.

34. Nurses should sign entries using their name as entered on the Register of Nurses. Nurses should affix their signature over printed name. The use of initial is not acceptable except on charts where there is a designated place where initials are used like drug administration record.

35. All entries must be dated.

36. Entries in the record must be in chronological order.

37. Documentation in the record must be carried out as soon as possible after providing nursing care.

38. It should always be clear from the notes what time an event occurred and what time the record was written.

39. Nurses should not “squeeze” a late entry into existing note, nor write in the margins.

40. Nurses ought not to chart entries ahead of time, or otherwise, predate entries.

41. Nurses ought not rewrite entries in the record or discard the originals, even if it is for a simple reason e.g. a torn page or a spilled drink.

42. All entries must be timed, especially where the condition of the patient is changing or liable to change frequently.

44. Urinalysis results (+++) are example of an official grading system.

45. ++,< > should be avoided except where part of an accepted grading system. Upward or downward arrows to denote changes in heart rate or other vital signs should not be used.

46. Measurements of lacerations, lesions, skin grafts etc must be in metric measurement. Avoid using terms such as small, medium, large.

47. Documentation should consist of the location and site, sizes, number of lesions treated and method of destruction.

48. Entries made in error should be bracketed and have a single line drawn through them so that the original entry is still legible. Errors should be signed and dated.

49. A nurse making a referral or consulting with another member of the health care team should clearly identify, by name, the person on the record.

50. All decisions to take no immediate action but review the situation later (“wait and see”) should be clearly documented.

51. Continuous assessment/monitoring and evaluation of a patient’s condition is a legitimate nursing intervention and it requires documentation within the record particularly in changing circumstances.

52. Any information, instruction or advice given, including discharge advice by a nurse to a patient should be documented.

53. All written data in respect of a patient/family should be kept in a designated area with a view to forming a complete single record.

54. The patient’s name and record number (hospital number) should appear on every page of the record.

55. Nurses should not, as a general rule, record or document care on behalf of someone else.

56. The standard of record keeping of those under supervision in the clinical area e.g. student nurses or nurse trainees, should be monitored by the nurse charged with responsibility for the supervision of her/his subordinate.

57. All documentations made by affiliates or trainees must be countersigned by the nurse-on-duty.

58. Regular audit is an integral part of maintaining quality record.

59. The practice of regularly auditing records has shown to improve the standard of record keeping and hence, patient care. It is recommended that nurse managers develop a system of regular audit of record keeping in order to monitor and maintain standards.