1. Record keeping or rather, poor record keeping is the ______ highest reason why registered nurses are removed from the professional register.

2. The Nursing and Midwifery Council (2015) states that nurses must ‘keep clear and accurate ______ relevant to your practice’.

3. Records are usually kept for a minimum of ______ years for an adult over 21.

4. There are three main legal aspects underpinning record keeping, these being: data protection, confidentiality and ______.

5. Patients can now request to see all of their medical records, they are no longer a secret. The ______ helped to bring this change about.

6. A student nurse you must have each record you write in a patients notes countersigned by a qualified nurse until they are deemed as ______ in record keeping.

7. The entry should have the time entered using a ______ clock.

8. The record should be written up as soon as possible after the episode of care and any temporary note taking, for example in an emergency situation, should be formalised within ______ hours.

9. Clients/patients records must be kept safe and stored appropriately to maintain ______.

10. TPR is an acceptable or unacceptable abbreviation.

11. Nurses often blame lack of ______ a reason for poor record keeping.

12. There is now a move towards ______ record keeping.

13. Record keeping is an integral part of care delivery and enhances ______between the health care team.

14. The NMC (______) code is the current published guidance for record keeping.

15. The fundamental principle in relation to record keeping is that if it is not recorded it did not ______.