NIPEC Record Keeping Guidance - Care Planning

Following assessment of a person's health care needs, there should be a record that demonstrates clearly the nursing interventions to be applied. The record should also outline what is the expected desired outcome of the interventions and how they have been evaluated. This should be recorded on the person’s daily progress and evaluation report.

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This section of the guide illustrates the principles of good record keeping during Care Planning

Important Point

The examples provided in this section focus on acute adult care. They will however demonstrate the principles of good record keeping practices which may be adapted to other care settings.

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