Theme 4: Record keeping

What went wrong at Gosport?

The Gosport Independent Panel highlighted:

• a consistent picture of poor record keeping and failure to record fundamental aspects of care and care monitoring
• record keeping was inadequate and it did not meet the expected standards of professional guidance as set out at that time.

What our Code says

Our Code of Conduct requires professionals to keep clear and accurate records relevant to their practice. It says, ‘This applies to the records that are relevant to your scope of practice. It includes but is not limited to patient records.’

What our standards say

Our current nursing standards say nurses must:

"maintain accurate, clear and complete records, including the use of electronic formats, using appropriate and plain language"

Our current midwifery standards say midwives must:

"Complete, store and retain records of practice which:

- are accurate, legible and continuous;
- detail the reasoning behind any actions taken; and
- contain the information necessary for the record’s purpose."

Our current nursing associate standards say nursing associates must:

"Demonstrate the ability to keep complete, clear, accurate and timely records".

Record keeping today

Nurses and midwives must keep clear, accurate and timely records of people in their care.

Our new standards make clear that when a problem arises or risks are identified, they must be logged, including the step taken resolve the issue so that other colleagues are able to carry out good and consistent care.

They also ensure that nurses will be equipped with the skills necessary to challenge colleagues and provide constructive feedback about the delivery of care.