Writing in a patient’s notes: tips for nursing students
Legible notes are required for professional record-keeping. Find out what makes good documentation and what to do if you make a mistake
Writing patient notes to a professional standard depends on having the right tools, including choosing the best pen for the job.
Why are patient notes so important?
Record-keeping is an integral part of nursing, midwifery and allied health professionals’ practice and is essential to the provision of safe and effective care, says NHS Professionals in its record keeping guidelines , which were reviewed and updated in 2021.
Records include anything that refers to the care of the patient and may be used as evidence in a variety of ways, including inquests, criminal proceedings, safeguarding