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The NMC report states the female patient, named Patient A, was vulnerable and was liable to form attachments. Between January and April.

In a legal sense, documentation and record keeping is also there for the protection of the nurse or healthcare professional. A well-kept record can protect the practitioner in instances where the legal defence of their actions is required. Documentation also ensures a matter of professionalisation and proof of the improvement of practices. Poor record keeping hampers the care that patients receive and makes it difficult for healthcare professionals to defend their practice.

Record keeping is a tool for professional practice and one that should help the care process. It is not separate and not an optional extra to be fitted in if circumstances allow. A record should be made as soon as possible after the patient is seen or the procedure is complete. Sometimes records may be requested by professional governing bodies when investigating claims related to misconduct NMC Therefore, you must take care about what you write.

It is therefore critical to keep up-to-date with the legal requirements and best practices of record-keeping, proving that:. A registered nurse is accountable for any delegation of record keeping to members of the multi-professional team who are not registered practitioners, such as assistant practitioners AP , care assistants and nursing students Jevon