Why record keeping matters so much in complaints and referrals
When a patient complains, or when an employer or regulator looks into an incident, the first thing anyone reads is the record. Months later, nobody remembers a shift in detail. The notes become the evidence of what you saw, what you thought and what you did.
That is why record keeping comes up in so many fitness to practise cases, even when the original concern was about something else. A nurse referred about a fall, or a doctor referred about a missed diagnosis, may find that the real difficulty is that the record does not show their assessment. If it is not written down, it is hard to prove it happened.
Every UK healthcare regulator sets standards on this. The NMC Code asks nurses, midwives and nursing associates to keep clear and accurate records, to complete them at the time or as soon as possible afterwards, and to note when an entry is written late. The GMC's Good medical practice (2024) says formal records must be clear, accurate, contemporaneous and legible. HCPC and GPhC standards set similar expectations for allied health professionals and pharmacy professionals.
What are the most common record keeping mistakes?
The same problems appear again and again in complaints, incident reviews and regulator decisions. Most are not about bad intent. They come from busy shifts, unfamiliar systems and habits nobody has ever challenged.
1. No entry at all
The observation was done, the patient was reviewed, the family was updated, but nothing was written. Later, the gap is read as the task not being done.
2. Late entries that are not labelled as late
Writing up notes at the end of a shift is common. The problem comes when a note written at 19:30 reads as though it was made at 14:00. That can look misleading, even when it was not meant to be.
3. Vague phrases that hide the clinical picture
Entries such as "settled", "comfortable", "no concerns" or "seen and reviewed" tell the next reader almost nothing. They do not show what you assessed or why you were reassured.
4. Decisions and conversations left out
Many complaints are about communication. If you explained risks, offered options, or discussed a decision not to treat, but did not write it down, you have no record that the conversation happened. The GMC lists decisions, including decisions to take no action, and the information shared with patients as things a record should usually include.
5. Copy and paste, and templates left unedited
Electronic records make it easy to copy yesterday's entry. Copied text can carry forward findings that are no longer true, such as a normal examination on a patient who has since deteriorated.
6. Unclear authorship
Entries made under someone else's login, unsigned paper notes, or notes where the time and author are missing all make it impossible to know who did what.
7. Unexplained abbreviations and jargon
Local shorthand may be clear to you and baffling to a patient, a lawyer or a colleague from another team. The NMC Code specifically warns against unnecessary jargon, abbreviations and speculation.
8. Opinions about patients written as fact
Labels such as "difficult", "attention seeking" or "drug seeking" can damage care, and patients increasingly read their own records. Describe what you observed and what was said instead.
9. Altering, backdating or adding to records dishonestly
This is the mistake that turns a training issue into a serious conduct case. It is covered in its own section below.
What should a good clinical note include?
There is no single template that suits every setting, and the level of detail should match the situation. As a general guide, a safe entry usually covers the points below.
- Date, time of the entry, and time of the event if different.
- Your name, role and signature, or your own login.
- What you found: observations, examination findings, the patient's own words where relevant.
- Your assessment: what you think is going on and why.
- What you did, and what you decided not to do, with the reason.
- What you told the patient or family, and their response or concerns.
- The plan, including who is responsible and when it will be reviewed.
- Any escalation: who you contacted, when, and what they advised.
| Standard | What it asks for in plain terms |
|---|---|
| NMC Code (section 10) | Records made at the time or soon after, late entries marked, risks and actions noted, accurate and honest, attributable, dated and timed, no needless jargon, kept secure. |
| GMC Good medical practice (2024) | Records clear, accurate, contemporaneous and legible. Usually include findings, decisions, information shared, patient concerns, and who made the record and when. |
| HCPC standards of conduct, performance and ethics | Keep full, clear and accurate records for everyone you care for, complete them promptly and keep them secure. |
| GPhC standards for pharmacy professionals | Records form part of delivering safe, effective, person centred care. Check GPhC guidance for setting specific expectations. |
Wording in each standard is updated from time to time. Always check the current version on your regulator's website.
Worked example: a weak entry and a stronger one
Here is the same nursing review written two ways. The patient is an older man on a surgical ward who was found sitting on the floor beside his bed.
Pt found on floor. No injuries. Back to bed. Obs fine. Will monitor.
14:20. Called to bay 3. Mr A found sitting on floor beside bed, says he slid while reaching for his drink. Did not hit head per patient and no visible injury. Alert, oriented, speaking normally. Full set of observations within his usual range (NEWS2 1). Checked limbs, no pain or deformity, moving all four. Assisted back to bed with hoist. Call bell and drink placed within reach. FY1 informed 14:35, will review this afternoon. Falls risk assessment updated, incident form completed. Daughter phoned 14:50 and informed. Plan: neuro observations as per falls policy, review by FY1. Signed with name, role and time.
The weak version is not wrong, but it cannot defend the nurse or protect the patient. It does not show whether a head injury was considered, who was told, or what the plan means in practice. The stronger version shows assessment, reasoning, escalation and communication, and it is still under 120 words.
Can you add to or change patient notes after the event?
Yes, you can add information later, as long as you do it openly. This is often the right thing to do if you realise something important is missing. What you must never do is make it look as though the new information was written at the original time.
- Write a new entry: Add a fresh entry with today's date and time rather than squeezing words into the old one.
- Label it clearly: Mark it as a late or retrospective entry and say which date and time it relates to.
- Explain briefly: Say why it is being added now, for example that you are recording a conversation you did not document at the time.
- Leave the original visible: On paper, draw a single line through an error so it can still be read, then initial, date and time it. Electronic systems keep an audit trail, so follow your local process for amendments.
- Stick to what you remember: Only record what you genuinely recall. Do not fill gaps with what you assume must have happened.
Why altering records is treated as dishonesty
Regulators separate two kinds of record keeping problem. Poor records, such as missing detail or messy notes, are usually seen as a competence issue that can be fixed through training, supervision and audit. Falsified records are seen as a question of honesty and integrity.
Examples that fall into the second group include backdating an entry, recording observations that were not taken, signing for medication that was not given, changing a note after a complaint to make your care look better, and asking a colleague to change their entry. Electronic audit trails mean that these changes are usually detectable.
Honesty is central to trust in the professions, so dishonesty findings carry a higher risk of serious sanctions. Concerns about falsified records are far harder to remedy than the original gap would have been. An honest, clearly labelled late entry is almost always the better choice.
Priya was coordinating a busy night and did not record two sets of hourly observations on a post-operative patient. In the morning the patient was found to be unwell, and she realised the chart had gaps. She was tempted to fill them in from memory. Instead she wrote a dated late entry explaining what she had checked and when, and told the nurse in charge. At the review, her honesty was noted, and the outcome was local learning on escalation and workload. Had she backfilled the chart, the same gap could have become a probity concern.
How to reduce your risk on a busy shift
- Write key entries straight after the event, even if brief, and expand later with a timed addition.
- Record escalations at the moment you make them, including the time and the name of the person you spoke to.
- Use your own login every time and lock the screen when you step away.
- Re-read anything you copy forward and delete what is no longer true.
- Write "discussed with patient" only alongside what was actually discussed.
- If you could not complete a task, say so and say why. A record that shows workload pressure is far safer than one that hides it.
- Ask for feedback on your notes in supervision or appraisal, and include a records audit in your CPD if you can.
For internationally educated staff, UK records can feel very different from what you were used to. Many systems expect more narrative, more detail about consent and communication, and less shorthand. It is reasonable to ask a senior colleague to look over a few of your entries during your first months.
If your record keeping has been criticised
If a complaint, incident review or regulator letter mentions your records, stay calm and act early. If you are under any formal investigation, contact your defence organisation, trade union or legal representative before you respond.
- Read the concern carefully and identify which records are in question.
- Do not change any existing entries.
- Reflect honestly on what was missing and why, including system factors.
- Complete relevant training and ask for a supervised audit of your notes over a few weeks.
- Keep evidence of the changes you have made, such as audit results and feedback from a supervisor.
Regulators look for insight and evidence of change, not perfection. A clear account of what you have learned, backed by evidence that your records have improved, is usually far more persuasive than a general promise to do better.
Related courses
If you want a structured way to work on this, our Record Keeping and Documentation: Remediation Course takes you through safe documentation, late entries and reflective evidence. If honesty or altered records are part of the concern, Probity and Dishonesty: Ethics Course for Healthcare Professionals covers how regulators view these issues. For doctors and others writing handover documents, Writing Safe Discharge Summaries focuses on one of the highest risk records in hospital care.
Frequently asked questions
Can a nurse be struck off for poor record keeping?
Poor record keeping alone is usually treated as something that can be remedied through training, supervision and audit, and many cases end without serious sanctions. The risk rises sharply when records are falsified, backdated or changed to mislead, because that becomes a question of honesty. Outcomes depend on the facts of each case, so anyone under investigation should seek advice from their union or defence organisation.
Is it acceptable to write notes at the end of a shift?
It is common and acceptable if you cannot write at the time, but the entry should show when it was written and the time of the events it describes. The NMC Code asks you to complete records as soon as possible after an event and to note when an entry is made late. Write brief notes of urgent events straight away.
How do I correct a mistake in patient notes?
On paper, draw a single line through the error so it remains readable, then write the correction with your initials, date and time. Never use correction fluid or remove pages. In electronic records, follow your organisation's amendment process, which keeps an audit trail. If a complaint or investigation has started, take advice before making any change.
What does contemporaneous mean in medical records?
Contemporaneous means made at the time of the event or as soon as possible afterwards. The GMC's Good medical practice uses this word for formal records. It does not mean every note must be written during the consultation, but delays should be short, and late entries should be clearly marked with the time they were written.
Can I use abbreviations in clinical records?
Widely understood abbreviations approved by your organisation are generally fine. Avoid local shorthand, ambiguous abbreviations, and abbreviations for drug names or doses, which can cause errors. The NMC Code asks you not to use unnecessary jargon or abbreviations. If a patient, lawyer or colleague from another team could misread it, write it out in full.
Should I tell anyone if I realise I forgot to document something?
Yes. Add a clearly labelled late entry as soon as you can, recording only what you genuinely remember, and tell the nurse in charge or your supervisor if the gap could affect care. Being open about an omission protects patients and is viewed far more favourably than a gap that is hidden or filled in dishonestly.
Related courses
Record Keeping and Documentation: Remediation Course
This course explains what good clinical documentation looks like, why record-keeping concerns arise, and why altering or falsifying a record is…
Probity and Dishonesty: Ethics Course for Healthcare Professionals
This course explains what probity means for UK healthcare professionals, how dishonesty arises in records, CVs, timesheets, sickness absence,…
Writing Safe Discharge Summaries
This course teaches doctors how to write a discharge summary that a GP can act on safely. It explains what GPs and community teams need, the national…
Sources and further reading
- The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Nursing and Midwifery Council.
- Good medical practice (2024). General Medical Council.
- Standards of conduct, performance and ethics. Health and Care Professions Council.
- Standards for pharmacy professionals. General Pharmaceutical Council.
- Records Management Code of Practice for Health and Social Care 2021. NHS England (Information Governance Alliance).
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
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