NURSE
NMC guidance:
https://nipec.hscni.net/download/projects/previous_work/highstandards_ed...
https://nipec.hscni.net/resource-section/improve-record-keeping/stds-of-recording-care/nmc-code-stds-record-keeping/
Royal College of Nursing guidance: https://www.rcn.org.uk/professional-development/publications/pub-006051
Keep clear and accurate records relevant to your practice.
This applies to the records that are relevant to your scope of practice.
It includes but is not limited to patient records.
To achieve this, you must:
- complete records at the time or as soon as possible after an event, recording if the notes are written some time after the event
- identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need
- complete records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements
- attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation
- take all steps to make sure that records are kept securely
- collect, treat and store all data and research findings appropriately