RCN guidance on record keeping and countersigning records

Published: 14 November 2012

The RCN has recently issued guidance for nursing staff (PDF 585KB) [see how to access PDF files], clarifying issues around delegating record keeping and countersigning records for HCAs, APs and registered nurses.

As a member of the wider health care team, the health care assistant (HCA), assistant practitioner (AP) or nursing student takes personal accountability for good record keeping. They must keep clear, accurate and timely records of care they provide to their patients to support communication, continuity and decision making. This includes all forms of patient records, such as anything that is documented about a patient and his/her care and treatment.

The RCN has also produced an A5 record keeping quick reference guide (PDF 758KB) which busts the myths and sets out key principles around record keeping. Join the RCN and the HCA and AP Network today and you can get this useful resource to help guide your practice in the workplace.

Please see the record keeping page in our professional issues section for more information.