Nursing records, created by nursing staff, encompass various records related to nursing care, including those for designated home nursing care. Additionally, midwifery records are maintained separately. These records capture the thoughts and actions of the nursing staff, documenting the series of processes involved in nursing practice. Generally, nursing records comprise four key elements: basic information about those under care, a nursing plan, progress records, and a nursing summary.

The purpose and significance of nursing records are multifold:
1. Clarify nursing practice.
2. Establish the basis of provided nursing care.
3. Serve as a means of exchanging information among medical teams, patients, and nursing staff.
4. Provide information on the patient’s mental and physical condition, medical status, progress of care provision, and outcomes.
5. Offer insights into problems faced by the patient, nursing practices for required care, and the patient’s reactions.
6. Verify that the facility complies with legal establishment criteria and medical record-keeping requirements.
7. Act as material for nursing evaluation, quality improvement, and development.

As per the 2007 amendment to the Medical Care Act, nursing records are required to be retained for two years (Medical Care Act Article 21, Paragraph 1, Item 9, Medical Law Enforcement Regulations, Article 20, Paragraph 10). Additionally, Article 42 of the Act on Public Health Nurses, Midwives, and Nurses mandates that midwifery records be kept for five years. Consequently, records made by nursing staff serve as crucial legal evidence, similar to medical records. Given contemporary trends such as information disclosure, it is essential to standardize records and terminology, clarify writing standards, enhance record quality, and provide ethics education on information management legal evidence, similar to medical records. Given contemporary trends such as information disclosure, it is essential to standardize records and terminology, clarify writing standards, enhance record quality, and provide ethics education on information management.

• Ibe, T., & Takemata, K. (Eds.). (2000). The future of nursing records: From “nursing records” to “patient records”. Japanese Nursing Association Publishing.
• Japanese Nursing Association (Ed.). (2005). Guidelines for handling nursing records and medical information. Japanese Nursing Association Publishing.
• Kuroe, Y. (Trans.). (1998). Mastering nursing records: Aiming to improve the quality of practice. Igaku-Shoin.
• Ministry of Health, Labour and Welfare. (2007, November 5). Overview of the Medical Care Act revision.
  Retrieved from http://www.mhlw.go.jp/shingi/2007/11/dl/s1105-2b.pdf