Clinical documentation can be delegated to HCAs, APs and student
nurses so that they can document the care they provide.
As with any delegated activity, the registered nurse needs to ensure
that the student or HCA/AP is competent to undertake the task and
that it is in the patient's best interests for record keeping to be
delegated.
Supervision and a countersignature are required until the
student/HCA/AP is deemed competent at keeping records.
Registered nurses should only countersign if they have witnessed the
activity or can validate that it took place.
Organisations providing health care should supply clear guidance on
clinical documentation for all staff, in line with the principles and
guidance in the NMC's Record keeping guidance (RCN 2012).
.
