“Because long after the patient leaves, your words remain.”

Nursing documentation is more than a legal requirement—it is a clinical, ethical, and professional safeguard. It communicates a patient’s journey across multidisciplinary teams, offers continuity of care, and most importantly, it can defend your actions when questions arise.

In a healthcare system where patient safety, communication errors, and litigation risks are real and rising, clear and timely documentation is no longer optional—it is essential (Griffith & Tengnah, 2020).

Legal Protection Poor or missing documentation is among the most common causes of professional misconduct referrals to regulatory bodies such as the NMC (Nursing and Midwifery Council, 2018). Courts often state: “If it is not documented, it did not happen.” Clinical Continuity Accurate documentation enables effective handovers, reduces duplication, and minimizes errors in care delivery (RCN, 2021). When multiple clinicians are involved, your notes may be the only reliable thread connecting assessments, decisions, and actions. Professionalism and Accountability Documentation reflects the nurse’s critical thinking, decision-making, and accountability (RCN, 2021). Poor notes can reflect poorly on your clinical judgement—even if your actions were correct.

According to the NMC Code (2018) and RCN guidance (2021), nurse documentation should always be:

✅ Accurate

✅ Complete

✅ Legible

✅ Contemporaneous (timely)

✅ Objective and factual

You should document:

Patient assessments (observations, complaints, behaviours) Care provided (e.g., repositioning, medication, wound care) Responses to care Escalations or referrals (who you spoke to, when, what was agreed) Any delays or refusals of care—and your response

1. Timeliness

Document as soon as possible after the event. Delays should be explained.

📝 “Documented at 22:15 following direct patient care. Event occurred at 21:45.”

Delays in documentation increase the risk of memory errors, inaccurate charting, and delayed interventions (Purkis & Bjornsdottir, 2006).

2. Objectivity

Stick to facts. Avoid assumptions, judgments, or emotional language.

✔️ “Patient observed pacing corridor, voice raised, clenched fists.”

❌ “Patient aggressive and acting crazy.”

3. Clarity and Structure

Use headings, time stamps, and Trust-approved templates when appropriate.

Avoid vague phrasing like:

❌ “Patient OK now.”

Replace with:

✔️ “Patient resting in bed, pain score 2/10, settled with repositioning.”

4. Escalation and Response

Always document when and to whom concerns were escalated, and what the outcome or plan was.

📝 “Escalated to SHO at 18:40 due to HR 126 bpm. Advised to monitor and recheck in 30 minutes.”

Symptom Documentation:

“Patient reports left-sided chest pain, described as sharp, 7/10, radiating to shoulder. Onset 17:20 while walking. Denies nausea or SOB. BP 140/88, HR 96, SpO2 98% RA. ECG performed—NSR. Referred to medical team.”

Mental Health Presentation:

“Patient pacing the corridor, verbally expressing frustration (‘I want to leave!’), appeared tearful. Denies thoughts of self-harm. Offered quiet space and reassurance. Escalated to site manager at 01:10.”

Refusal of Treatment:

“Patient declined paracetamol at 10:15, stating ‘I don’t want any more tablets today.’ Risks explained. Will re-offer later. Remains alert and pain score 5/10. No signs of distress.”

Medication Administered:

“Administered Co-codamol 30/500mg x2 orally at 13:40 as per drug chart. Observed taking with water. Pain score reassessed 45 minutes later—reduced to 3/10. No side effects noted.”

Overuse of copy-paste entries

Retrospective entries without date/time/justification

Abbreviations not on the Trust’s approved list

Documenting assumptions (e.g., “probably due to anxiety”)

Emotional language or blaming tone (e.g., “being difficult”)

In a shift full of clinical decisions, emotional conversations, missed breaks, and endless alarms—writing can feel like a chore. But your documentation is more than a task. It is a record of your presence. Your judgment. Your care.

In busy NHS wards where staff rotate and patients move fast, your notes might be the only story that stays.

So write like it matters—because it does.

Nursing and Midwifery Council (2018). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. London: NMC.

Royal College of Nursing (2021). Record Keeping: Guidance for Nurses and Midwives. RCN Publications.

Griffith, R., & Tengnah, C. (2020). Law and Professional Issues in Nursing. 5th ed. Sage.

Purkis, M. E., & Bjornsdottir, K. (2006). “Struggling with contradictory discourses: Nurses’ documentation practices.” Journal of Nursing Management, 14(7), 617–624.

NHS Resolution (2022). Learning from Litigation: Key themes from clinical claims.