Record-keeping: why nurses need all the support they can get

Writing up notes is a fundamental nursing task, and getting it wrong can become a fitness to practise matter. But we have resources to help you get the job done

Misconduct in record-keeping is among the most common allegations proved in Nursing and Midwifery Council (NMC) fitness to practise processes.

It was the third most common category upheld at adjudication in 2022-23 after patient care and, prescribing and medicines management, according to the regulator’s annual TfP report. These three concerns have been the most prevalent since 2020.

A recent FtP case we reported involved a nurse who altered a patient’s clinical notes after the person had died. In reaching its decision to strike the nurse off, the NMC panel concluded her actions were ‘premeditated, serious and sustained’.

• RELATED: Nurse struck off for altering patient’s notes after death

Writing up nursing notes can be a time-consuming task

Falsifying records is obviously at the extreme end of the misdemeanour spectrum. The vast majority of nurses know the importance of good record keeping – and, certainly would never embellish a patient’s notes after their death to create a false record of clinical activity, as happened in this case.

• RELATED: Record-keeping and documentation: how to get it right

However, record-keeping is a time-consuming and often stressful task done by exhausted staff at the end of a busy shift, outside core working hours. Nurses are human and errors or memory lapses do happen. Given staffing and service pressures, it’s often not possible to write notes up as you go.

Allowances should be made for mistakes and it’s best to make amendments as soon as possible, while complying with local policy. Covering errors up is, obviously, not okay.

• RELATED: Record-keeping and documentation: how to get on top of these fundamental nursing tasks

Resources to support you to achieve best practice in record-keeping

We know that nurses are looking for best practice and efficient and effective ways of record-keeping, as shown by interest in our resources on this topic. You can find them here and we are producing new content on the subject too.

• RELATED: Maintaining best practice in record keeping and documentation

Few of you will look forward to doing your notes but if you see them as a concise communication tool to enhance patient safety then they should stand up to scrutiny – and keep everyone safe.