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Please wait while the page loadsYear 1 Essentials · Free Resource
How to write notes that are clear, useful, and actually sound like nursing documentation.
Why documentation matters
Good records provide continuity of care between shifts, legal protection for you and your patient, communication across the MDT, an evidence base for clinical decisions, and they're required by the NMC Code of Conduct.
Records must be:
Clear & Accurate
Factual, consistent, and without jargon patients wouldn't understand
Legible
If handwritten, must be readable. Use black ink.
Timely
Documented as soon as possible after care is given
Signed & Dated
Full name, designation, date and time on every entry
Without Alterations
No correction fluid. Single line through errors with signature.
Contemporaneous
Made at the time of the event, or as soon as practical
Use SBAR for handovers, escalations, and documenting phone calls to doctors:
S
Situation
What is happening right now?
"I'm calling about Mr Smith in bed 4 who has become acutely short of breath."
B
Background
What is the clinical context?
"He's 78, admitted with COPD exacerbation yesterday, was stable on 2L O2."
A
Assessment
What do you think the problem is?
"O2 sats 85%, RR 28, NEWS 7 — I'm concerned he's deteriorating."
R
Recommendation
What do you need?
"I'd like you to come and review him urgently please."
Poor documentation
Good documentation
Paper Records
Electronic Records
Key Rules
Caldicott Principles
Documentation timing reference
Medication administration — document immediately after giving. Significant events — as soon as safe to do so. Escalations/doctor calls — immediately with time noted. Deteriorating patient — in real-time if possible. Record retention: 8 years for adults, 25 years for children/maternity records.
Documentation don'ts
When documentation is critical