How to Write Nursing Notes in the UK

Nursing documentation forms the backbone of quality patient care and professional communication. For newly qualified nurses, writing effective patient notes can feel overwhelming, but mastering this skill ensures patient safety and meets professional standards.

Good clinical records enable seamless care handovers and meet Nursing and Midwifery Council (NMC) requirements. Your documentation creates a legal record that protects both patients and nursing staff.

Five Essential Documentation Principles

1. Write Clearly and Legibly

Unclear handwriting causes medication errors and treatment delays. Poor documentation puts patients at risk.

• Use black ink for permanent paper records

• Write neatly - lives depend on readable notes

• Choose quality pens that won't smudge or fade

• Embrace electronic systems where available to eliminate handwriting issues

2. Document All Communication

Record every important conversation about patient care. Missing information breaks the care chain.

• Quote direct speech using quotation marks for accuracy

• Note conversations with patients, families, doctors, and colleagues

• Capture concerns expressed by anyone involved in care

• Follow NMC guidelines for comprehensive record keeping

3. Record Within 24 Hours

Fresh memories create accurate records. Delayed documentation leads to errors and missed details.

• Write immediately after patient contact when possible

• Never exceed 24 hours as per NMC requirements

• Capture details while observations remain clear

• Make timely recording a non-negotiable habit

4. Use the PIE Structure

Problem, Intervention, Evaluation creates logical, professional notes that colleagues can follow easily.

Example:

• Problem: Patient oxygen saturations dropped to 88%

• Intervention: Administered 2L oxygen via nasal cannula

• Evaluation: Saturations improved to 96%, continue hourly monitoring

5. Know What to Document

Record everything that impacts patient care, safety, or recovery. When in doubt, document it.

Essential Documentation Checklist

Patient Status Changes

• Mental state - alert, confused, agitated, drowsy

• Mobility levels - independent, assisted, bedbound

• Vital sign abnormalities and your response

• Pain assessment - location, severity, interventions used

Clinical Care Delivered

• Medications administered - dose, route, time, patient response

• Wound care - appearance, treatment, healing progress

• Food and fluid intake - amounts, difficulties, preferences

• Elimination patterns - bowel and bladder function changes

Communication and Education

• Patient concerns and how they were addressed

• Family discussions about care plans or prognosis

• Patient teaching provided and understanding demonstrated

• Care handovers between shifts or departments

UK Legal Requirements

Professional Standards

Every nursing note must include:

• Date and time using 24-hour format

• Your signature plus printed name and designation

• Approved abbreviations only as per trust guidelines

• Patient confidentiality maintained per data protection laws

Documentation Best Practices

• Use objective language - describe what you observe, not what you assume

• Avoid personal opinions - stick to facts and measurable outcomes

• Never alter entries - draw single line through errors and initial

• Keep records secure following information governance protocols

Common Documentation Pitfalls

Avoid These Mistakes:

• Writing notes days after patient contact

• Using unauthorized abbreviations or text speak

• Recording assumptions instead of observations

• Missing signatures or timestamps

• Including irrelevant personal details

Building Documentation Confidence

Effective nursing documentation improves with practice. Focus on accuracy first - speed develops naturally over time.

Start with these habits:

• Carry a notebook for quick observations during shifts

• Review your notes before submitting to catch errors

• Ask experienced colleagues for feedback on your documentation style

• Stay updated on trust-specific documentation policies

Need support with nursing documentation?

Professional development never stops. Access resources and training to strengthen your clinical documentation skills.

Remember: Quality documentation protects patients, supports colleagues, and demonstrates your professional competence.