Record-keeping and documentation: how to get on top of these fundamental nursing tasks
Your guide to writing clear, timely and concise records – plus tips for effective handovers and how to communicate in the multidisciplinary team
Accurate record-keeping is a vital part of good communication in nursing and integral to safe and effective practice.
The point is underlined by the Nursing and Midwifery Council (NMC) code, which states that to practise safely, nurses must keep clear and accurate records relevant to their practice.
Nursing documentation is essential for good clinical communication. Effective record-keeping also promotes consistency while ensuring professional standards are upheld in line with the Code, with records allowing members of the multidisciplinary
Want to read more?
Unlock full access to RCNi Plus today
Save over 50% on your first three months:
- Customisable clinical dashboard featuring 200+ topics
- Unlimited online access to all 10 RCNi Journals including Nursing Standard
- RCNi Learning featuring 180+ RCN accredited learning modules
- NMC-compliant RCNi Portfolio to build evidence for revalidation
- Personalised newsletters tailored to your interests