Professionalism in nursing 4: record keeping, consent and capacity

Record keeping is an essential part of a nurse's role and can have both ethical and legal implications; however, common errors and omissions persist. This article is part four in a series on professionalism and, as well as exploring good record keeping, it discusses patient consent and capacity. Consent can be informed, implied, verbal or written, depending on the situation, and must be documented in the patient's notes. Capacity legislation must be followed to ensure a patient is able to make their own informed decisions.

This article has been double-blind peer reviewed

In this article…

• How to improve patient care through good record keeping and avoid common errors

• The types, validity and legal implications of patient consent

• The importance and complexity of assessing patient capacity

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Key points

Record keeping is integral to the nurse's role, but common errors are made

Poor record keeping can result in professional or legal implications for nurses

Consent can be implied, informed, verbal or written, and must be obtained before carrying out care

Mental capacity is an individual's ability to understand information and use it to make informed decisions

Legislation states how patients' mental capacity should be assessed