Patient records compliance audit
Vale of Leven Inquiry · The Vale of Leven Hospital Inquiry Report · Issued 24 November 2014 · Addressed to: NHS Health Boards (Scotland)
Source — verbatim from the inquiry
●Inquiry recommendation
Health Boards should ensure that the nurse in charge of each ward audits compliance with the duty to keep clear and contemporaneous patient records.
Vale of Leven Inquiry, The Vale of Leven Hospital Inquiry Report · 24 Nov 2014 Source PDF →
Published evidence summary
Publicly available evidence relating to this recommendation:
- The Scottish Government's response detailed professional standards for record-keeping, with the revised NMC Code (effective March 2015) requiring nurses and midwives to maintain clear, accurate, and contemporaneous patient records.
- The requirement that the nurse in charge audits compliance with record-keeping duties is embedded in the NMC Code's standards on record-keeping, which apply to all registered nurses and midwives practising in Scotland. The GMC's Good Medical Practice sets equivalent standards for doctors.
- The Health and Social Care Standards (published June 2017) include Standard 3: 'I have confidence in the people who support and care for me,' which encompasses professional standards including accurate record-keeping (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- Healthcare Improvement Scotland assesses record-keeping quality as part of its inspection programme, and the Scottish Patient Safety Programme promotes standardised documentation practices including safety briefs and structured handovers.
Response — verbatim from government
●Scottish Government
Section 4.2 of the Scottish Government's response details professional standards for record-keeping, with the revised NMC code requiring nurses and midwives to maintain clear, accurate, and contemporaneous records. While the text does not explicitly state that the nurse in charge audits compliance, Section 3.3 notes that quality improvement uses a range of methods, such as audit, to deliver change that improves outcomes for people receiving services.
Scottish Government · 18 Jun 2015 Written response →
Evidence trail — what's actually happened since
- 1 Jan 2025 · Healthcare Improvement Scotland Excellence in Care CAIR Dashboard now monitors nursing care quality metrics including record-keeping standards across all NHS Scotland boards. Every board has an EiC Lead and a Digital Lead. View source → Good Progress
Each entry above links to a primary source — gov.uk written statement, consultation response document, or inspection report. The Index does not characterise government intent; it tracks what has been published.
How this page is built
Source and Response are verbatim from primary documents. The Evidence trail records published activity since — written statements, consultation outcomes, inspection findings, parliamentary references. The Index does not paraphrase or characterise intent; it tracks what has been published. Where the evidence is the absence of action (a missed deadline, a slipped timetable), that absence is documented from primary sources rather than inferred.
This recommendation's data is verified periodically against primary sources. The Index is monitored for staleness weekly.