Nursing record

The nursing record forms part of the overall medical record for a patient and provides a formal record of the interaction between the nurse and the patient. It is also a form of communication between the nurse and other health professionals.

Nurses may record some details about patients other than in the nursing record, such as in informal notes. Still other observations may never be written down, especially behavioural, social, or psychological knowledge of the patient that often exists as tacit knowledge. Such tacit knowledge provides a richer context for understanding and treating the patient.