NMC Code Section 10: Keep Clear and Accurate Records

Section 10 of the Code is the documentation standard.

“Keep clear and accurate records relevant to your practice.”

Sub-clauses:

• 10.1 Complete records at the time or as soon as possible after an event, recording if the notes are written some time after the event.
• 10.2 Identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need.
• 10.3 Complete records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements.
• 10.4 Attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation.
• 10.5 Take all steps to make sure that records are kept securely.
• 10.6 Collect, treat and store all data and research findings appropriately.

Section 10 is the section most directly tested in fitness-to-practise hearings, because the records are usually the primary evidence of what happened.

What it means in practice

Records have three functions:

• Clinical: the next professional needs to know what happened, what was decided, what was done.
• Legal: records are evidence in negligence claims, criminal cases, and fitness-to-practise hearings.
• Professional: records demonstrate that the care delivered met the standards required.

The single principle: records should be such that a competent colleague reading them later could understand what happened, what you observed, what you concluded, and what you did. Records that meet that test are usually adequate for legal and professional purposes too.

Contemporaneous documentation (10.1) is the bedrock standard. Records written at the time are stronger evidence than records written hours or days later. Late records are permitted (necessity of clinical work means immediate documentation isn’t always possible) but the time gap should be noted in the record itself.

Common breaches

Section 10 breaches in fitness-to-practise cases:

• Falsification: entries that didn’t happen, signatures forged, vital signs invented. The most serious category and the one most likely to end registration.
• Substantial omission: failure to record events that did happen, particularly when something subsequently went wrong.
• Late or absent corrections: discovering an error and not correcting the record properly.
• Inadequate detail: entries so brief that they don’t support the clinical decision.
• Inappropriate abbreviations: using shorthand that wasn’t standard, leading to confusion in handover.

Falsification is the category that most directly ends careers. A single falsified entry, when discovered, is usually enough for a fitness-to-practise hearing and often for removal from the register.

CPD that maps to Section 10

• Record keeping training (often included in induction and refreshed every few years).
• Electronic patient record system training when new systems are introduced.
• Information governance training.
• Legal aspects of nursing records: short courses on records as evidence.
• Documentation audit participation: auditing records against standards is itself learning.

Common reflective account themes

Strong Section 10 accounts describe:

• A near-miss caught by a previous record being clear.
• A documentation gap you discovered and addressed.
• An audit cycle you contributed to that improved record quality on a ward.
• A discussion with a junior colleague about how to document a difficult event.

The accounts that work usually involve concrete behaviour change: a specific change in how the registrant documents, often prompted by an event where the record proved either valuable or inadequate.

Where Section 10 connects to other sections

• Section 7 (communicate clearly): records are written communication.
• Section 14 (duty of candour): accurate records support open disclosure.
• Section 22 (registration requirements): false records can be grounds for removal.

The next chapter covers Code Section 11: being accountable for decisions to delegate.