Reflective accounts

Record-keeping and documentation

A CPD article updated Lucy Ward’s knowledge on the purpose and process of maintaining accurate patient records

A CPD article updated Lucy Ward’s knowledge on the purpose and process of maintaining accurate patient records

Abstract

A patient’s notes, assessments, care plans and letters are all evidence of the care and treatment they received. This CPD article highlighted how patient records are clinical tools that act as evidence of care, or the lack of it, and are relevant to every nurse’s practice.

Documentation is important to maintain continuity of care and treatment. Changes in a patient’s condition are more difficult to monitor without accurate record-keeping and documentation.

Read the article

This reflective account is based on NS742 Beach J, Oates J (2013) Maintaining best practice in record-keeping and documentation. Nursing Standard. 28, 36, 45-50.

This article is for subscribers only