title: Record-keeping and documentation.
abstract: A patient's notes, assessments, care plans and letters are all evidence of the care and treatment they received. This CPD article highlighted how patient records are clinical tools that act as evidence of care, or the lack of it, and are relevant to every nurse's practice.
authors.affiliation: Jersey General Hospital in St Helier, Jersey, and is currently based in Northfleet, Kent.
authors.forename: Lucy
authors.initials: L
authors.lastname: Ward
mesh_terms: D057286:Electronic Health Records / Q000458:organization & administration*; D005568:Forms and Records Control / Q000458:organization & administration*; D006801:Humans; D008499:Medical Records; D024802:Nurse's Role; D009737:Nursing Records; D006113:United Kingdom