To record or not to record: documentation in clinical supervision

Area of Science:

• Nursing Practice
• Professional Development

Background:

• Clinical supervision is crucial for nurses, yet record-keeping practices remain an unresolved issue.
• Existing literature on clinical supervision recording is limited, leading to uncertainty among practitioners.

Purpose of the Study:

• To review the literature on record-keeping in clinical supervision for nurses.
• To explore trainee supervisees' concerns regarding different recording approaches.
• To provide guidelines for effective record-keeping in clinical supervision.

Main Methods:

• Literature review on clinical supervision record-keeping.
• Analysis of three case studies illustrating trainee supervisee concerns.
• Discussion of issues arising from different recording positions.

Main Results:

• Three primary recording positions identified: supervisor audit records, supervisee learning journals, and supervisor aide-mémoire notes.
• Trainee supervisees express concerns related to these three recording approaches.
• The study highlights the necessity of addressing recording issues at the outset of supervision.

Conclusions:

• There is no single 'perfect way' for record-keeping in clinical supervision.
• Consideration of recording practices is beneficial for both new and experienced supervisors and supervisees.
• General guidelines are proposed to assist practitioners in navigating clinical supervision record-keeping decisions.