General Nursing (RGN)

Documentation and Recording of Patient Care

Accurate recording of relevant patient assessment, nursing care, interventions and response in the appropriate clinical record.

Purpose

Provide an accurate record of patient care.
Support continuity of care.
Communicate relevant clinical information.
Provide evidence of care and patient response.

Indications

After relevant nursing assessments.
After nursing interventions.
When significant changes occur.
As required by clinical documentation policy.

Equipment

Approved patient record
Approved documentation system
Appropriate writing or electronic documentation tools

Procedure steps

Confirm the correct patient record.
Review relevant information before documenting.
Record assessments and care accurately.
Use clear and appropriate clinical language.
Record significant patient responses and changes.
Document medications and interventions according to policy.
Complete entries promptly.
Identify the person making the entry according to policy.
Maintain confidentiality and security of records.
Communicate significant findings to the appropriate healthcare professional.

Precautions

Maintain patient confidentiality.
Do not falsify or alter records improperly.
Use the approved documentation system.
Record objectively and accurately.
Follow institutional documentation policies.

Educational resource only. Follow current Nursing and Midwifery Council guidance, local institutional protocols, scope of practice, and clinical supervision.

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