Record keeping is one of the most common themes in NMC cases: in 2024-25 it made up 13% of allegations found proved at NMC hearings, behind patient care and medicines management. The NMC treats an honest but inaccurate record very differently from a falsified one. Poor records raise questions about practice that can often be strengthened; falsified records raise questions of dishonesty, which the NMC treats among its most serious concerns.
Key takeaways
- Record keeping was the third most common category of allegations found proved in 2024-25.
- Inaccurate or incomplete records are a practice concern; falsified records are a dishonesty concern.
- A late entry should be clearly marked, dated and never replace or alter the original.
- Training, audit and reflection on the Code's record keeping standards are strong evidence of change.
Many nurses referred over record keeping were working under real pressure: short staffing, interrupted shifts, systems that do not talk to each other. That context matters, but so do records, because the next person caring for the patient relies on them. This article explains how the NMC approaches these concerns. It is general information, not legal advice.
Why do records feature in so many NMC cases?
The NMC's annual fitness to practise report for 2024-25 shows the most common categories of allegations found proved at hearings were patient care (19%), prescribing and medicines management (15%) and record keeping (13%). Within record keeping, the NMC groups concerns about patient or clinical records and about drugs or medication records. Record keeping saw a small increase compared with the year before.
The Code includes standards on keeping clear and accurate records relevant to your practice. Those standards are usually the reference point when a concern about records is raised.
What is the difference between inaccurate and falsified records?
This distinction shapes the whole case.
- Inaccurate, incomplete or late records: notes that are missing, vague, recorded in the wrong place or written up late. These raise questions about clinical practice, competence or systems. They can often be addressed through learning and support, and the NMC says undertakings may suit misconduct related to clinical practice.
- Falsified records: recording something you know did not happen, such as observations that were not taken, care that was not given, or another person's signature. This is an allegation of dishonesty.
Sometimes a case starts as one and becomes the other. A missed observation is a practice issue. Writing it in afterwards as though it had been done is not.
Can falsifying records lead to being struck off?
It can. The NMC's guidance on striking-off orders lists cases involving dishonesty or a breach of the professional duty of candour among the types of case most likely to result in removal from the register. That does not mean every falsified record leads to striking off: panels consider the facts, the context, insight and strengthened practice, and must work through the sanctions in order, from a caution order upwards.
If your case involves an allegation of dishonesty, read facing an NMC dishonesty allegation alongside this article.
How do I make a retrospective entry properly?
If you realise something was not recorded, the honest answer is a clearly marked late entry, not a quiet correction. General good practice, which your organisation's records policy will build on, is to:
- Make a new entry clearly labelled as a late or retrospective entry.
- Record both the date and time you are writing it and the date and time of the event it describes.
- Never alter, delete or write over the original record.
- Record only what you know, and say where it comes from if it is based on memory or someone else's account.
- Sign or authenticate it in the usual way, and tell the nurse in charge if the gap could affect care.
If an NMC case is already open, do not go back into records to add or tidy anything. Take advice first, and only access records you have a current, legitimate reason to see.
What does strengthened practice look like for record keeping?
The NMC's guidance on responding to a case recommends sending evidence of steps you have taken to address the concerns, such as courses or extra training, and any insight or reflections. For records, that often means:
- Targeted learning on documentation and the Code's standards on records, with notes on what you took from it.
- Regular audits of your own notes with a supervisor or manager, and the results.
- A reflective piece on why accurate records matter for patient safety and continuity of care.
- Testimonials from a manager who has reviewed your documentation since.
Use the CPD and remediation evidence log to track your evidence, and the NMC Code of Conduct course to work through the Code's standards. The Code explained is a shorter introduction.
What should I do now?
- Contact your union or professional indemnity provider.
- Note the dates in your letter. The NMC says you have 14 days from the date on the letter to respond to the allegations, though you do not have to respond to them in that time; you do need to send the personal details form and your employer's details.
- Write a private timeline of the shifts involved, including staffing and the systems you were using.
- Do not contact anyone connected to the case.
- Start your reflection and learning now; it can be part of your evidence later.
When should I get legal advice?
Early, and especially if the word falsified or dishonest appears anywhere in the concern. Contact the RCN, RCM, Unison or Unite if you are a member, or your indemnity provider. If you are not in a union, the NMC encourages you to seek advice from a regulated legal professional with experience in regulation, such as a regulatory solicitor.
The NMC's Careline offers free, confidential support from an independent provider, 24 hours a day, on 0800 587 7396.
Frequently asked questions
It can be. Record keeping made up 13% of allegations found proved at NMC hearings in 2024-25. Many record keeping concerns are about practice and can be addressed through learning, supervision and reflection.
Writing notes late is not falsification in itself, as long as the entry is clearly marked as late, dated when written, and accurate. It becomes a dishonesty concern if a record claims something happened that did not.
Follow your organisation's policy. Generally, add a new, dated entry explaining the correction and never delete or overwrite the original. If an NMC case is already open, take advice before touching any records.
Evidence that your documentation has improved: training certificates with reflection, audits of your notes by a supervisor, a reflective piece and testimonials from managers who have seen your recent records.
