UK NMC Recordkeeping Standards

The Nursing and Midwifery Council (NMC) sets out the standards for recordkeeping for nurses, midwives, and nursing associates in the UK. These standards are crucial for ensuring patient safety, accountability, and continuity of care. Here’s how your points align with the NMC’s requirements:

1. Document evidence:

• The NMC Code states that you must keep “clear, accurate, and factual records” of your practice (Standard 10.1). This includes assessments, interventions, evaluations, decisions, and the rationale behind them.
• Good documentation serves as evidence of your actions and decisions, which is vital for:
  • Providing continuity of care: Colleagues can understand the patient’s history and make informed decisions.
  • Addressing complaints: Accurate records can help defend against allegations of misconduct.
  • Demonstrating accountability: You can be held accountable for your practice, and your records support this.

2. Liability/accountability:

• By keeping clear and accurate records, you are demonstrating your accountability for your actions and decisions.
• This is essential for maintaining public trust in the nursing and midwifery professions.
• The NMC Code emphasizes the importance of acting with honesty and integrity (Standard 1.1) and taking responsibility for your practice (Standard 5.1).

3. Provides continuous flow of care with colleagues:

• Sharing accurate and comprehensive records with colleagues ensures everyone involved in the patient’s care has the necessary information.
• This facilitates seamless handovers, reduces the risk of errors, and promotes collaborative care.
• The NMC Code highlights the importance of collaboration with colleagues (Standard 4.2).

4. Helps address any complaint:

• Thorough documentation can be invaluable when responding to complaints or concerns.
• Clear records can help clarify situations, demonstrate adherence to best practices, and support your professional conduct.
• The NMC encourages open and honest communication when addressing concerns (Standard 9.2).

5. Must be legible, signed and dated:

• The NMC requires records to be legible, signed, and dated to ensure authenticity and clarity.
• This helps maintain the integrity of the records and prevents misunderstandings.
• Illegible or unsigned records may be deemed inadmissible if concerns arise.

Additional resources:

• The NMC Code: https://www.nmc.org.uk/standards/code/
• Records Management Policy: https://www.nmc.org.uk/globalassets/sitedocuments/data-protection/records-management-policy.pdf