You are likely to have come across a large number of documentation in clinical practice such as care plans, admission and discharge forms, treatment plans, drug charts, observation sheets, behavioural assessments, investigation reports, capacity assessments, behavioural plans, safeguarding reports, documentation for detention under the Mental Health Act, epilepsy charts, incident/accident reports etc. Remember as a student nurse you will also have many records that need completing.

What do you feel are the main principles of accurate record keeping? Consider areas such as safety, practicalities, key information, storage, language and legal and ethical considerations

Some of the main principles of accurate record keeping are that they need to be factual, understandable, secure, identify risks and proposed actions, logical, confidential, signed and dated and in line with local policy and national guidance (see NMC 2015 Code, section 10 in particular)

In relation to each of the four fields of nursing, what additional considerations would you need to make? For example, children, people with learning disabilities, dementia or mental health needs

Additional considerations – these may centre on making information from various records accessible for those with disabilities. For example, the use of technology, visual and hearing aids, translation services, communication aids and bespoke storage and security measures.  Children may need a parent or carer to explain matters and those with disabilities may have an advocate to support them in providing information, ensuring confidentiality and keeping patient held records safe and secure.