Standards & Guidance

Recording clinical practice: guidance

recording clinical practice cover

Good recording keeping is part of the professional and legal accountability of registered nurses and midwives. This guidance from the Nursing and Midwifery Board of Ireland, formerly An Bord Altranais, aims to assist nurses and midwives to:

  • Appreciate the professional and legal issues around compilation and management of documentation.
  • Value professional responsibility associated with good practice in record management.
  • Offer practice advice in attaining and maintaining acceptable standards of recording clinical practice.

The guidance includes sections on:

  • The purpose of good record management.
  • Confidentiality.
  • Documenting consent to treatment.
  • Legal considerations.
  • Use of records in research.

It also includes guidelines to assist nurses and midwives to establish and maintain accurate, clear and current records.

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Recording Clinical Practice: Professional guidance

(PDF, 0.61 MB)


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