Issues surrounding record keeping in district nursing practice

Abstract

This article examines some aspects of nursing documentation following the publication of the document 'Guidelines for Records and Record Keeping' (UKCC, 1998). The importance of nursing documentation in patient care, in guiding practice and in providing information for members of the interprofessional healthcare team is highlighted. Record keeping forms an important part of the clinical governance initiative in terms of quality improvement and risk management. The issues surrounding the legal requirements of record keeping in district nursing practice are discussed. Suggestions are made for assessing the quality of nursing documentation by audit and research, in order to establish the suitability of using the present systems in the community setting.