How to Maintain Exceptional Record Keeping

In the heat of an emergency or after a never ending stream of uncooperative or difficult patients, sometimes the idea of paperwork and accurate data recording is difficult for nurses to fully apply themselves to.


Yet exceptional record keeping is an essential skill that all nurses must learn and then complete perfectly on a day-to-day basis if they want to succeed and progress in the medical sector.


A patient’s medical history and progression of treatment, the amount of drugs that are accessible for use and reports on major incidents all need to be definitively documented by nurses in order for the optimal running of a ward or a care system.


Every organisation will have it’s own policies and procedures when it comes to records and requirements for nurses. Make sure to familiarise yourself with these as soon as you begin working at a new place of work or return after an extended period of absence.


Red Flag Documenting


In the event that a nurse presides over an incident or patient that they believe could result in a court case, it is imperative that any red flag situation is documented as quickly and in as much detail as possible. These incidents include:


  • Alcohol-related situations such as traffic coalitions, family violence and assaults.
  • Cases involving drug use
  • Incidents involving gunshot wounds e.g. size, entry and exit points, approximate distance and calibre of gun
  • Assaults and rapes
  • Poisonings
  • Injuries on duty
  • Deaths after an anaesthetic or therapeutic procedure
  • Unexpected complications e.g. reactions to drugs, falls from beds or cardiac arrests
  • Persons currently incarcerated who have to go to hospital.

In the event that you are dealing with an emergency, always take some notes on a piece of paper to remind you of important aspects that have to be remembered when a full report is written at a later stage. Such aspects can include the time of the incident, medication given or stock used, activities performed and outcomes obtained.


Best Practices

Remember, even if you have already manually done something for the benefit of a patient’s care or comfort, for the wider institution as a whole if it has not been written, it has not been done.


A failure to cite or document any procedure could result in hazardous or even fatal consequences for patients due to a toxic mixture or incorrect dosages of drugs.


With these points in mind, here are Search Medical’s top six tips to ensure exceptional record keeping.


  1. Complete all records at the time or as soon as possible after an event or treatment is given. If the notes are written some time afterwards, record what was done to make recollection easier.
  2. Identify any risks or issues that have arisen and the steps taken to deal with them. This will ease the work for colleagues who use the records in the future.
  3. Complete all records accurately with no falsification. Take immediate action if you become aware that someone has not followed these requirements.
  4. Do not include unnecessary abbreviations, jargon or speculation
  5. Attribute any entries you make in any paper or electronic records to yourself and make sure all the text is clearly written, dated and timed.
  6. Once written, take every precaution to ensure that records are kept securely and are stored in an appropriate location. 


Search Medical is a specialist in not only sourcing and placing nursing jobs but also guiding our workers through some of the most important issues surrounding the profession. If you have any questions regarding exceptional record keeping please contact a member of the Search Medical team in your nearest England office.


By John Murphy  



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