Fluid balance monitoring
Health Boards should ensure that where patients require fluid monitoring as part of their critical care, nursing staff complete fluid balance charts as accurately as possible.
- 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 fluid balance charts are completed accurately for patients requiring fluid monitoring 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, provides specific guidance requiring clear and accurate records to be maintained. Nurses must complete all records at the time or as soon as possible after an event, ensuring all information needed by colleagues is present. This includes signing, dating, and timing their entries to ensure accurate documentation of critical care elements like fluid balance.
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 CAIR Dashboard monitors fluid balance chart completion as part of fundamentals of care metrics across all NHS Scotland boards.
View detailed findings
Fluid balance monitoring is one of the ratified CAIR measures tracked nationally.