What is a nursing record?

The nursing record is where we document the nursing care the patient receives and their response to it, as well as any other events or factors that may affect the patient's well-being. These 'events or factors' can range from a visit by the patient's relatives to going to theatre for a scheduled operation.

What should go into a patient's nursing record?

If you are in doubt about what to write, it may be useful to ask yourself the following: “If I was unable to give a verbal handover to the next nursing team, or the next shift, what would they need to know in order to continue to care for my patients?” You want to ensure that the patient's care is not affected by the changeover of nursing staff.

How to keep good nursing records

The patient's record must provide an accurate, current, objective, comprehensive, and concise account of their stay in hospital. Traditionally, nursing records are hand-written. Do not assume that electronic record keeping is necessary.