Patient notes: record-keeping dos and don’ts for students

Nursing students need to be able to maintain accurate, clear and timely patient notes to ensure effective communication, safety and continuity of care. Students should learn how to keep patient records professional, yet free of jargon, avoiding abbreviations. Patient notes can also serve as legal evidence and should reflect what happened as well as what didn’t. A professor of nursing and a nursing student offer tips and techniques for factual, neutral record-keeping that also captures the patient’s own voice.