Record Keeping in Nursing

The provision of healthcare services is based on information obtained from various sources at all levels of care, and such information underpins decision making in healthcare. Keeping complete and accurate records is therefore part of clinical care provision, although often not seen as such.

Well-kept records become an advocacy tool speaking for both the patient and the practitioner as they tell a story about the patient’s health history and the care he or she has received. The need for more emphasis on the skill of record keeping is what this publication aims to address.

It discusses the reasons why keeping records of healthcare service delivery is important; the management of nursing records and the writing of incident reports; laws and ethics related to record keeping; and records as a communication tool