[CG] Record keeping guidance for nurses and midwives

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Abstract

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The way in which nurses and midwives keep records is usually set by their employer. The NMC recognises that, because of this, nurses and midwives may use different methods for keeping records. However, the principles of good record keeping are well established, and should reflect the core values of individuality and partnership working.

Good record keeping is an integral part of nursing and midwifery practice, and is essential to the provision of safe and effective care. It is not an optional extra to be fitted in if circumstances allow.

National programmes for the use of information communication technology and electronic record keeping are being introduced throughout the UK. Although electronic records are evolving, it is clear from nurses and midwives that paper based records are still commonly used. This guidance applies to both paper and electronic records. It explains what we expect from all nurses and midwives.