Record keeping

Some of the documents on this page are in PDF format [see how to access PDF files]

Introduction

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 NMC Code includes principles for effective delegation (paragraphs 29-31) and the NMC has also produced its own guidance on delegation and record keeping (PDF 265KB). The RCN has issued guidance for nursing staff (PDF 585KB) drawing on these principles to clarify the issues of delegating record keeping and countersigning records.

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.

Principles of record keeping

1. Record keeping can be delegated to HCAs, APs and nursing students so that they can document
the care they provide.
2. Record keeping is an integral part of every intervention and the HCA/AP or student should be assessed as competent in the complete provision of care, which includes record keeping. Until they are deemed wholly competent in both the activity and its documentation, countersigning as in principles four and five should be performed.
3. As with any delegated activity, the registered nurse needs to ensure that it is in the patient’s best interests for the activity and documentation to be delegated to the HCA/AP or student.
4. Supervision and a countersignature are required until the HCA/AP or student is deemed competent at the activity and keeping records. The principles of accountability and delegation apply (see www.rcn.org.uk/hcaaccountability)
5. Registered nurses should only countersign if they have witnessed the activity or can validate that it took place.
6. Organisations providing health care should supply clear guidance on record keeping for all staff, in line with the principles and guidance in the NMC’s Record keeping guidance.

Always refer to local policy in the first instance.