Documentation Standard ( for Nurses, Midwives and Peri-Operative Practitioners )

Publication: 01/10/2005  --
Last review: 27/04/2018  
Next review: 27/04/2021  
Standard Operating Procedure
ID: 666 
Approved By: Standard agreed by LTHT Strategic Documentation Group (March 2016) 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  


This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Documentation Standard (for Nurses, Midwives and Peri-Operative Practitioners)


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All individuals involved in the documentation of care are expected to adhere to this standard and to have read the NMC Record keeping: Guidance for nurses and Midwives (2015). In addition to the NMC guidance, additional guidance specific to LTHT is given below. This standard applies to all nurses, midwives and peri-operative practitioners.

Ward and department managers are responsible for ensuring that systems and processes are in place to ensure this standard is adhered to in their clinical area and by all staff.

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The LTHT standard for records requires them to be;

  • up to date
  • dated, timed and signed at each entry
  • have the practitioners name and designation printed on each page
  • are factual, do not include any unnecessary jargon and only include abbreviations  on the LTHT approved list of abbreviations;  
  • countersigned for any entries where a registered practitioner was supervising a student or unregistered practitioner undertaking the task.
  • For clarity nursing students and competent unregistered practitioners can independently document care they have delivered, using the standards in this document, as long as a competency assessment has been completed

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Electronic Documentation

The principles for good record keeping outlined by the NMC (2009) apply equally to records stored electronically. In addition, the NMC (2009) stipulate that nurses should be aware of, and know how to use, electronic information systems available in Professional and Trust standards for the management of health records apply to all media (paper and electronic) held within the organisation. Information held within Trust recognised electronic health records forms part of the medico-legal patient record and does not need to be printed and stored in the paper case notes. At present the Trust operates a ‘hybrid’ health records management system reflecting the fact that the organisation is migrating from a predominantly paper based system to one that is electronic. As such, some relevant information may not be captured electronically and will only be available through the paper case notes.

Access to electronic systems must be controlled by the IT department. There is a requirement to have completed Information Governance and PAS training prior to the granting of access to a system (Health Records Management Policy). The LTHT “Use of Computer Facilities Policy” stipulates that it is not permitted at any time to use another person’s personal username and password or SmartCard and PIN to gain access to any part of the Trusts computer systems.

The Trust’s current recognised electronic health records are:

  • WinDip (Healthview)
  • PACS
  • ppm+
  • ePRO (Winscribe)
  • eDAN (Bluespier)
  • Ordercomms
  • Medical Image Manager (MIM)

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Location of documentation

The intention of these standards is that they support the nursing process with a convention of assessment, planning, implementation and evaluation. Each patient may have examples of the documentation in Table 1


Usual Location

Completed by

Time frame for completion

Biographical details 

Nurses station

Registered practitioner


Assessment of care needs (a  range of tools are available, including both paper and electronic assessments)

Patient’s bedside or via electronic device

Usually Registered practitioner

Commenced within 4 hours and fully completed (inc. additional assessments) within 24 hours of admission to clinical area

Observation chart (s)

Patient’s bedside or via electronic device

Registered practitioner or competent unregistered practitioner

As determined by ‘Physiological Observations in Adult Patients’ guideline -
Within 30 minutes of admission and at a minimum 12 hourly

Pressure area care and falls risk assessments and care plans

Patient’s bedside or via electronic device

Usually Registered practitioner

Within 6 hours of admission

Care plans

Patient’s bedside or via electronic device

Registered practitioner or competent unregistered practitioner

Within 12 hours of admission to clinical area

Evaluation of care

Patient’s bedside or via electronic device

Registered practitioner

At least once every shift (of any length)

Communication sheet

Nurses station

Registered practitioner

At least once every 24 hours

Discharge Documentation

Nurses station or via electronic device

Registered practitioner

Commenced on day of admission

Table 1

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Admission - Assessment

  • The LTH standard is every patient’s initial assessment will be completed by a registered practitioner.
  • All patients must have biographical details completed/checked immediately on admission to a clinical area (including next of kin name and contact details), and a full nursing specialist assessment or equivalent commenced within 4 hours of admission to the clinical area.
  • More detailed assessments such as Pressure Ulcer and Falls etc should be completed within 6 hours. If the condition of the patient means this is not possible, this should be documented within the communications section with a timescale for remaining actions.
  • If any information not currently available, plans must be made to obtain it as soon as possible. This can be documented in the appropriate section of the nursing specialist assessment or equivalent.
  • It is the responsibility of the person completing the patient’s admission to ensure the nursing specialist assessment or equivalent is completed in full. This will usually be a registered practitioner. There maybe are exceptions to this if agreed by Matrons and Heads of Nursing after consultation with Governance Forums.
  • During assessment, where a patient has an identified need this will trigger a more detailed assessment, and will always result in a plan of care being completed. This must be done within 24 hours of the patient’s admission.
  • The nursing specialist assessment or equivalent must  be updated on any change of condition, when the patient is transferred to another ward or a minimum of weekly if there are no significant changes

Care Planning

  • All patients must have a plan of care completed within 12 hours of their admission to the clinical area.
  • All patients must have plans of care that reflect the needs identified from the nursing specialist assessment document or equivalent.
  • Assessment areas may use the short stay nursing specialist assessment document
  • Care plans will be used alongside LTHT care standards, and will identify the required nursing care and further treatments/tests required.
  • All sections of each care plan must be completed and individualised.
  • If there is no pre-printed care plan for the care need identified the registered practitioner must use the LTH standard blank care plan to detail the care required based on best practice evidence;


  • All care plans must be revised in accordance with any change of condition, and at least once every shift (of any length).


  • Each care need identified must be evaluated every 24 hours as a minimum.
  • The relevant evaluation of care given on every shift (of any length) will be written directly on the care plan with any variances to care written on the same plan.
  • If any new nursing needs are identified, the relevant care plan should be added, and the nursing specialist assessment documentation or equivalent updated.
  • Individual care plans may be evaluated by an unregistered practitioner. A blank evaluation form should be used by the registered practitioner to document an overall evaluation of care, at least once every shift (of any length).


  • Any additional information related to the patient’s care, such as communication with the patient or their relative, medical changes etc, may be documented in the communication section of the nursing record kept at the nurses’ station or in the MDT progress notes for patients on assessment units.

Transfer to other wards

  • The transfer checklist form must be fully completed for all transfers between wards and departments, where the patient will be staying in the receiving area. This should then be attached to the patients notes prior to transfer.
  • Following transfer between wards, a check should be made by the receiving ward that documentation is completed and follow up any outstanding areas for completion.
  • Further information about transfer of patients can be found;


Discharge documentation

  • It is the responsibility of a registered practitioner to commence the required documentation for discharge from the day of admission.
  • Any existing care plans should be evaluated with any ongoing care which will be needed on discharge resulting in a referral to community services.


Record: 666

This standard provides a structured, consistent approach to all documentation while adhering to legal and professional requirements of the Nursing and Midwifery Council. Leeds Teaching Hospital Trust (LTHT) uses care plans, care standards and multi-professional documentation that support an Integrated Care Pathway approach to care. There is an expectation that care standards will reflect the evidence base available and incorporate best practice guidance.

Clinical condition:


Target patient group: All patients
Target professional group(s): Secondary Care Nurses
Allied Health Professionals
Adapted from:

Evidence base

Standard agreed by LTHT Strategic Documentation Group (February 2018)

Approved By

Standard agreed by LTHT Strategic Documentation Group (March 2016)

Document history

LHP version 1.0

Related information

Not supplied

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.