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Keeping records as a self-employed nurse: what good records look like

Published · updated · sources read 28.10.2026

Contents
  1. What the standards say
  2. What to write at each visit
  3. Wounds
  4. Correcting without erasing
  5. Storing and protecting
  6. When someone covers for you
  7. Checklist
  8. Sources

The essentials

When you work for yourself, nobody keeps the records for you. The NMC Code asks every nurse in the UK to keep clear and accurate records; in Ireland, NMBI guidance asks for every entry to be signed, dated and timed. This guide turns those standards into a routine that holds up on the road, between visits, with the record on your phone.

What the standards say

Section 10 of the NMC Code, “Keep clear and accurate records relevant to your practice”, asks you to:

  • “complete all records at the time or as soon as possible after an event, recording if the notes are written some time after the event” (10.1);
  • “complete all records accurately and without any falsification” (10.3);
  • “attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed” (10.4);
  • “take all steps to make sure that all records are kept securely” (10.5).

In Ireland, NMBI’s “Recording Clinical Practice” lists, among its principles: “All entries are signed”, “All entries are dated”, “All entries are timed”, and for an error, “No attempt should be made to alter or erase the entry made in error.”

None of this asks for a particular tool. It asks for records that are contemporaneous, attributable and secure, whatever you write them on.

What to write at each visit

  • At the start of care: your nursing assessment, using a recognised model (for example Virginia Henderson’s 14 needs or Marjory Gordon’s 11 functional health patterns), the problems, the goals.
  • At every visit: the real date and time, what you did, what you observed, how the person responded.
  • Assessment scales: the name of the scale, the score and the date, every time.
  • Risks and the steps taken: so that a colleague who reads the record has what they need (NMC Code 10.2).
  • Communication: with the GP, the family, whoever covers for you. Who, when, what.

Wound assessment at home: photos, measurements, progress

A wound is followed over time: site, classification, size, wound bed, exudate, edges and surrounding skin, with the date of each assessment. A photo adds to the description; it does not replace it. A wound photo is health data: it does not belong in your personal camera roll, next to family pictures.

Correcting without erasing

A mistake is corrected by adding, never by erasing: the original entry stays readable, and the correction carries its own date, time and author. That is what makes a record credible on the day someone reads it back.

Storing and protecting records that travel

Data protection law (UK GDPR in the UK, GDPR in Ireland) treats health data as a special category, and names pseudonymisation and encryption among appropriate security measures (Article 32). At home visits the risks are practical: a bag left in the car, a lost phone, a shared laptop.

  • Records encrypted on the device, behind a passcode or biometrics.
  • A regular backup, also encrypted.
  • No records sent through a personal messaging app.

When someone covers for you

Holidays, illness: the nurse covering for you needs the round, the care due and the latest notes, not the whole history on a loose sheet. When you come back, their access ends.

Checklist

  • Every entry is dated, timed and attributed to you.
  • Late entries say they are late.
  • The assessment, problems and goals are written down.
  • Every scale has its name, score and date.
  • Every wound has its history: dated assessments, measurements, photos.
  • Corrections are added; the original stays.
  • Records are encrypted on the device, and backed up.

What Carnet does for you

Carnet is the nursing record on your phone, even offline. Tick off a visit on your round: it goes into the patient’s journal with the real date and time, and your name once it is set in the settings. A correction is added; the original stays. The assessment follows the model you choose, Henderson or Gordon; goals and focus notes follow the model of the record. Wounds are assessed with recognised classifications (NPIAP, Wagner, ISTAP…) and the TIME framework; photos are encrypted, inside the patient’s record. Scales (Norton, 4AT, GDS-15, GAD-7 and others) record the score and its published interpretation in English, with the date. A validated scale is never re-translated: its items stay in French until an official English version is integrated, and the screen says so. Each patient’s record exports to PDF, ODT or DOCX.

Your records are encrypted on your device, with a key the publisher does not hold. With the managed plan: encrypted backup, sync between your phone and your computer, and cover access that you close when you return.

What Carnet does not do: it sends nothing to an insurer or a public scheme, it does not do your accounts, and it gives no clinical advice.

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Sources

This guide quotes texts read on 28.10.2026 and gathers good practice; it is not legal advice and does not replace your regulator’s guidance. It gives no clinical advice.

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