NMAHP record keeping

Record keeping (documentation) is a fundamental professional responsibility that supports safe, effective and person-centred care. It involves documenting assessment, planning, implementation, and evaluation of care provided to patients and service users by registered practitioners and non-registered practitioners and care providers working under direction/supervision of a registered practitioner.

Record keeping is an integral part of Nursing, Midwifery and Allied Health Professional practice and influences the care process. The quality of record keeping reflects the standard of individual professional practice. Good record keeping is a sign of a safe and skilled practitioner. The principles of good healthcare record keeping are well established and should reflect the person centred care core values that care is coordinated, care is enabling and care is personalised.

Allied Health Professionals (AHPs) are required to follow the record keeping standards outlined by The Health and Care Professions Council. AHPs have a professional responsibility to keep full, clear, and accurate records to safeguard continuity of care by providing information to colleagues involved in care and treatment. This is also required to ensure service users receive appropriate treatment that is in their best interests and to meet legal requirements or respond to Freedom of Information or Subject Access Requests; and evidence decision-making processes if later queried or investigated.

Accurate record keeping is fundamental to safe, effective, and person-centred care. It supports continuity of care, informed clinical decision-making, and effective communication between healthcare professionals. As well as being a professional and legal requirement, clinical records provide a vital source of evidence of the care delivered.

The Data Protection Act 1998 defines a health record as ‘consisting of information about the physical or mental health or condition of an identifiable individual made by or on behalf of a health professional with the care of that individual’

Good record keeping helps to protect the welfare of patients in our care by promoting;

• High standards of care.

• Accountability.

• Continuity of care.

• Improved communication and dissemination of information between members of the multi-disciplinary team and patients.

• An accurate account of treatment, care planning and care delivery.

• The ability to identify changes in a patient's condition promoting timely and appropriate intervention to support the delivery of safe, effective and high-quality care.

Good record keeping helps to protect the welfare of staff by;

• Demonstrating how decisions are made.

• Providing documented evidence of care/services delivered.

• Facilitating the management of complaints or legal process.

• Support Quality Improvement, Quality Assurance, Audits and Research.

The principles of good documentation and strict confidentiality apply to all types of records, regardless of how they are held. These include;

• Paper

• Digital

• Email

• Scanned

• Audio/Video recordings

• Photographs/medical imaging

• Microform (microfiche/microfilm)

• Instant messaging/SMS

• Social media posts

• Website content (internet/intranet)

• Safeguard continuity of care by providing information to colleagues involved in care and treatment

• Ensure service users receive appropriate treatment that is in their best interests

• Meet legal requirements or respond to Freedom of Information or Subject Access Requests and

• Evidence your decision-making processes if later queried or investigated.

The Health & Care Professions Council (HCPC) Professional Standards of conduct, performance and ethics standard 10 (record keeping) state;

• 10.1. You must keep full, clear, and accurate records for everyone you care for, treat or provide other services to.

• 10.2. You must complete all records promptly and as soon as possible after providing care, treatment or other services.

• 10.3. You must keep records secure by protecting them from loss, damage or inappropriate access.

Clear, accurate, and timely record keeping is a fundamental aspect of professional practice and plays a key role in demonstrating the quality, safety, and person-centred nature of care. Legislation, including the Human Rights Act 1998, the Data Protection Act 2018 and UK GDPR, has increased patients’ rights to access their health records and has reinforced the importance of maintaining comprehensive and contemporaneous documentation. Records are frequently relied upon when responding to feedback, concerns, or complaints about care; therefore, it is essential that nurses, midwives, and allied health professionals remain up to date with legal requirements and best practice standards. The Nursing and Midwifery Council (NMC) Code and Health and Care Professions Council (HCPC) standards emphasise that records should be completed contemporaneously or as soon as possible after the event. Where this is not achievable, the reason for delay should be clear, and the entry should be made at the earliest opportunity in accordance with professional standards and local policy.  Avoid vague, subjective or non-specific language such as "comfortable", "settled" or "slept well" unless supported by objective observations or further explanation.

HCPC provides excellent guidance for practitioners on their website as to the expectations for AHP record keeping with FAQs and a webinar session for practical advice and educational support.

A patient’s documentation should provide a clear and concise account of the treatment and care given and allows for good communication between the MDT.

Depending on the setting and type of record there will be variation in specific content and style, however broadly this should demonstrate;

• Compliance with record-keeping standards by ensuring the patient's name, date of birth and unique identifier are present on every page or digital screen, using a printed addressograph label on paper records wherever possible.

• Good record-keeping practice by ensuring all entries are clearly attributable to the author and are legible, dated and timed using the 24-hour clock.

• Clear and effective record keeping by using only approved abbreviations and ensuring they are legible and unambiguous. Where an abbreviation is used, the term should first be written in full with the abbreviation provided in brackets to reduce the risk of misinterpretation.

• Accurate documentation by avoiding jargon and speculation, ensuring entries are based only on observed, reported or assessed facts.

• Accountability and professional record keeping by ensuring all handwritten care records are signed and include the author's name in clear print together with their professional designation.

• Good record-keeping practice by ensuring all handwritten and printed entries are completed in indelible black ink.

• Compliance with documentation standards by ensuring all corrections are dated, timed and signed by the author. Handwritten errors should be crossed out with a single line, so the original entry remains legible, with the reason for the amendment clearly recorded. Correction fluid or correction tape must not be used.

• Accurate record keeping by blocking off any unused space after entries and avoiding gaps between lines and paragraphs.

• Accountability and safe practice by ensuring all entries made by students are countersigned by a supervising registered practitioner.

• Effective record keeping by documenting care in chronological order as close to the time practicable. Each record should be factual, consistent and accurate.

• Timely and accurate record keeping by documenting care at the time of the event whenever possible. Retrospective entries should not be routine; where they are unavoidable, they must be clearly identified as retrospective documentation.

• Professional and accountable record keeping by ensuring all documentation is authenticated, accurate and truthful, reflecting only what was observed, discussed or completed, without omissions, assumptions or unsupported information.

• Clinical records should include:

  • relevant clinical findings

  • the decisions made and actions agreed and by whom

  • the information that has been given to patients and relatives

  • investigations, treatments including drugs that have been prescribed.

AHPs should follow the HCPC Standards of Proficiency. How these standards are demonstrated will depend on the individual's profession, role, local policies, and guidance issued by professional bodies and membership organisations.

Records should be maintained in accordance with legal requirements and professional standards. Decisions relating to record keeping should be informed, reasonable and capable of being explained and justified when required.

• Clinical records provide important evidence of assessment, decision-making and care delivered. Where care or interventions are not documented, it may be difficult to demonstrate that appropriate actions were taken.

• Documentation that includes patient identifiable information should be stored securely to maintain confidentiality. Documentation containing patient-identifiable information must only be sent via secure NHSAA email account.

• Personal information about patients held by health professionals is subject to a legal duty of confidence.

• The content of documentation should include information that allows the reader to fully understand the events that have occurred and be able to comprehend the care delivered.

• Adhere to the confidentiality requirements, codes of conduct and professional standards set by the regulatory and professional body.

• Adhere to NHS AAA Health Records Management Policy for accessing health records.

• Patient’s records should be stored out of sight from members of the public and should not be left unattended at any time.

• Demonstrate that where necessary local guidelines relating to risk management have been followed and critical incidents reported.

• Infusion charts have equipment type and serial number clearly documented.

Risk management

Documentation should clearly demonstrate:

• Escalation of concerns

• Safeguarding discussions

• Capacity assessments

• Consent discussions

• Clinical reasoning underpinning decisions

• Duty of candour actions where applicable.

• Record keeping can be delegated to students to document the care they have provided.

• The registered practitioner must deem the student competent to undertake the task and that it is in the patient's best interest.

• Supervision and a countersignature are required depending on your profession and governing body.

• Countersigning should only be undertaken when the information documented is accurate and can be verified, when the activity has been directly witnessed, or when there is sufficient evidence to validate that the activity has taken place.

Digital documentation must follow the same principles which apply to paper documentation with added attention to security;

• Laptops and computers must be password protected to ensure the user can be identified.

• Do not share usernames or passwords with anyone.

• Do not leave electronic systems open.

• Laptops are encrypted and verification of the encryption process is required by NHS AAA for data protection.

• Electronic documentation entries are locked and cannot be altered.

• Take reasonable measures to ensure a secure network.

• Where digital tools, clinical decision support systems or generative AI technologies are used to support documentation, healthcare professionals remain professionally accountable for ensuring records are accurate, person-centred, clinically relevant and validated prior to entry into the patient record.

Audit provides assurance whilst supporting education, practice supervision, improvement and governance reporting. Evidence of learning, actions taken and subsequent re-audit should be documented to demonstrate continuous improvement. Therefore, every healthcare provider must ensure:

• Records are audited using a record keeping tool.

• Audit cycles and formats are agreed by profession and assurance is reported through appropriate governance structures.

• There is evidence that actions have been taken and learning has been implemented as a result of the audit findings.

All health records are legal, confidential documents. Accurate record keeping is both a professional and legal requirement providing a clear account of care delivered. Health records may be used as legal evidence and, in a court of law, if it has not been recorded, it has not been done.

Good record keeping helps to protect the welfare of patients in our care of any age by;

• promoting high standards of care

• accountability

• continuity of care

• effective communication.

Good records should be;

• accurate

• objective

• timely

• relevant

• legible

• person-centred

• respectful

• evidence informed.

  and reflect the individual's expressed wishes, preferences, strengths, protected characteristics, communication needs, and evidence involvement in decisions about their care.

Royal College of Nursing (RCN), Record Keeping (2023)

Records Management Code of Practice for Health and Social Care (2021 updated June 2026)

Health and Care Professions Council (HCPC) Record Keeping Standards (2021)

Nursing & Midwifery Council (NMC) Professional Code of Conduct (2015)
Read The Code online 

Health and Care Professions Council. Our expectations for your record keeping

Nursing & Midwifery Council. Record keeping: guidance for nurses and midwives

NHS Professionals. Record keeping guidelines. CG2

General Medical Council (GMC) – Good Medical Practice

The Medical Defence Union – Effective record keeping

Nursing and Midwifery Council. The code: Professional standards of practice and behaviour for nurses, midwives and Nursing Associates. 

Data Protection Act 2018. 

Human Rights Act 1998.

UK Government. Data protection.

UK General Data Protection Regulation (UK GDPR) 2021.

NHS AAA Health Records Management Policy
NHS AAA Equality, Diversity and Human Rights Policy