CDI patient observations records
Health Boards should ensure that nursing staff caring for a patient with CDI keep accurate records of patient observations including temperature, pulse, respiration.
- The Scottish Government's response detailed professional standards for record-keeping, with the revised NMC Code (effective March 2015) requiring nurses and midwives to maintain clear, accurate, and contemporaneous patient records.
- The requirement that nursing staff keep accurate records of observations for CDI patients is embedded in the NMC Code's standards on record-keeping, which apply to all registered nurses and midwives practising in Scotland. The GMC's Good Medical Practice sets equivalent standards for doctors.
- The Health and Social Care Standards (published June 2017) include Standard 3: 'I have confidence in the people who support and care for me,' which encompasses professional standards including accurate record-keeping (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- Healthcare Improvement Scotland assesses record-keeping quality as part of its inspection programme, and the Scottish Patient Safety Programme promotes standardised documentation practices including safety briefs and structured handovers.
How was this evidence gathered?
Response
Accepted
Response
AcceptedSection 4.2 of the Scottish Government's response outlines professional standards for record-keeping. The revised NMC code, which all nurses and midwives must follow, specifically requires them to complete all records accurately and without any falsification, and to identify any risks or problems and the steps taken to deal with them. This guidance ensures that nursing staff maintain clear and accurate records of patient observations.
Published Evidence
Published assessments of progress from inspectorates, select committees, official progress reports, and other sources. Source type badge indicates whether each assessment is independent or government self-reported.
Excellence in Care framework includes patient observation recording standards. CAIR Dashboard monitors compliance with nursing documentation requirements across all boards.
View detailed findings
National standardised approach through Excellence in Care addresses patient record keeping requirements.