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Box 8.1 Some Types of Record Used by the Nursing Associate

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Nursing assessment recordsNursing care plansObservation chartsFluid balance chartsRisk assessmentsMedication chartsIncident formsCommunication pages

Patients can have access to their record by law (this will be discussed later), and this also puts a professional onus onto the nursing associate’s record‐keeping ability. Patients may want to see their records for clarification of the care that they have received or because they feel that there has been negligence; if they lack capacity according to the Mental Capacity Act (2005), they may have an advocate who can read their records so that they are in a better position to assist the multidisciplinary team to make decisions in the patients’ best interest.

The Nursing Associate's Handbook of Clinical Skills

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