TVN instructions recorded
Health Boards should ensure that where a TVN is involved in caring for a patient there is a clear record in the patient notes and care plan of the instructions given.
- 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 TVN instructions are clearly recorded in patient notes and care plans 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 addresses this through professional standards for record-keeping. The revised NMC code, which nurses must follow, requires clear and accurate records to be maintained, completed at the time of an event, and to identify any risks or problems and the steps taken to deal with them so colleagues have all necessary information. The GMC also requires doctors to keep clear, accurate, and legible records of concerns and actions taken. The Scottish Government's Records Management: NHS code of practice (Scotland) further guides required standards of practice for record-keeping.
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 monitors care documentation including specialist nursing instructions. CAIR Dashboard tracks documentation compliance.
View detailed findings
National frameworks address documentation requirements for specialist nursing input.