TO:              NATIONAL DEPARTMENT OF HEALTH

                      PROVINCIAL DEPARTMENTS OF HEALTH

                      NURSING EDUCATION INSTITUTIONS

                      ALL RELEVANT STAKEHOLDERS

SUBJECT:       THE IMPORTANCE OF DOCUMENTATION AND SAFE RECORD-KEEPING BY NURSE PRACTITIONERS

PURPOSE

This circular is aimed at reminding all nurse practitioners about the critical importance of documentation and safe record-keeping in nursing practice.

BACKGROUND

• The South African Nursing Council is a statutory body that is empowered by the Nursing Act 2005, (Act No. 33 of 2005) to protect the healthcare users in matters involving delivery of health services and particularly nursing services as entrenched in Section 3(a) of the Nursing Act, 2005. In its endeavour to protect the healthcare users the Council established a Preliminary Investigating Committee (PIC) in terms of Section 15 of the Nursing Act, 2005 (Act No. 33 of 2005). The role of PIC is to investigate all reported cases of alleged unprofessional conduct against nurse practitioners to ensure that the practitioners who provide nursing service to healthcare users are competent and provide nursing care with reasonable skills and knowledge and in line with the National Core Standards for Health Establishments in South Africa.
• Accurate and prompt documentation is essential in patient safety, legal protection, professional accountability and continuity of care.

• On analysis of reported cases of alleged unprofessional conduct by nurse practitioners to PIC, it was noted with concern that some of the cases are due to the failure to document nursing care provided to the health-care users as well as safe record-keeping in accordance with relevant legislation and ethical standards.

COUNCIL RESOLUTION

The Council ordinary meeting held on 4-5 August 2025 therefore resolved that a Circular should be issued to remind nurse practitioners about the importance of documentation and safe record-keeping.

DIRECTIVE

All nurse practitioners are reminded about the following critical factors:

• Ensure that records are completed in real-time or as soon as possible after the provision of care.
• All records must be signed, timed and dated including writing of the nurse’s full name with a signature. This is to ensure that the recorded information is traceable to the person who provided the care.
• The record must be correct, clear and legible.
• If one makes a late entry, the date must not be backdated but mark it as a late entry with the date and time one is writing it.
• Avoid overwriting, rather cross out and write anew.
• Ensure that the patients’ files are safely placed in the dedicated places as per hospital policy and the POPI Act, 2013/PAIA Act, 2000.

IMPLICATIONS

The contents of this Circular must be brought to the attention of all nurse practitioners employed in different sectors.

Enquires should be directed to Ms. SJ Nxumalo, Deputy Registrar at [email protected] or Tel: 012 420 1059.

______________________

PROF NG MTSHALI

REGISTRAR & CEO

DATE:  ________________________  

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