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Please wait while the page loadsYear 1 Essentials · Free Resource
How to write notes that are clear, useful, and safe, without overcomplicating what good documentation looks like.
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Student note
Good documentation is not about sounding impressive. It is about helping the next person understand what happened, what you did, what changed, and what needs doing next.
Write for the next reader
Good records help care stay joined up between shifts, protect both you and the patient, and support team communication.
Document promptly
Write things down as soon as it is safe to do so. Memories fade quickly, and contemporaneous notes carry more weight.
Be specific
"Patient fine" tells the next person nothing. Say what you observed, what you did, and what changed.
Follow NMC standards
The Nursing and Midwifery Council sets the standards for record keeping. They are also part of your professional accountability.
What your notes need to be, every time.
Clear & accurate
Legible & timely
Signed & dated
No alterations
A four-part structure for handing over clearly, escalating concerns, and recording phone calls to doctors.
S — Situation
B — Background
A — Assessment
R — Recommendation
Side by side, so you can see the difference.
Poor documentation
Good documentation
What to do when you write something wrong.
Paper records
Electronic records
How to handle patient information safely.
Key rules
Caldicott Principles in plain English
When to write things down, and how long records are kept.
| Event | When to document |
|---|---|
| Medication administration | Immediately after giving |
| Significant events | As soon as it is safe to do so |
| Escalations or doctor calls | Document straight away, with the time |
| Deteriorating patient | In real time if possible |
| Record retention (adults) | Usually 8 years |
| Record retention (children / maternity) | Usually 25 years |
Things that make notes unsafe
When documentation is critical
Also practice with