ABSTRACT
Nurses make decisions through the creation and development of a narrative about the patient. These decisions should be recorded. There are many reasons why it is necessary to record decisions, including: professional obligation; so that the employing organisation can demonstrate that holistic, safe and effective care is being given; and fault trace when this does not occur, as part of governance and risk management. Comments about the quality of records raised questions about where else nurses looked for information about what is happening with a patient. One source that was cited was a ward-round book. The written record consisted of an assessment sheet, a care plan and a free-text continuation sheet. The assessment sheet allowed different types of information to be recorded.
