NMC Code – Standards Relevant to Record Keeping

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There are standards throughout the Code that are indirectly related to record keeping practice.  Click on the links below which are specifically about record keeping practice:

 


  • Prioritise People

    4.2 make sure that you get properly informed consent and document it before carrying out any action (Page 6)

  • Practise Effectively

    7.1 use terms that people in your care, colleagues and the public can understand (Page 7)

    10 Keep clear and accurate records relevant to your practice
    This includes but is not limited to patient records. It includes all records that are relevant to your scope of practice.

    To achieve this, you must:

    10.1 complete all records at the time or as soon as possible after an event, recording if the notes are written sometime after the event

    10.2 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

    10.3 complete all records accurately and without falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements

    10.4 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

    10.5 take all steps to make sure that all records are kept securely, and

    10.6 collect, treat and store all data and research findings appropriately (Page 9)

  • Preserve Safety

    14.3 document all these events formally and take further action (escalate) if appropriate so they can be dealt with quickly (Page 12)