Documentation is any written or electronically generated information about a client that describes the care or service provided to that client. It is an essential part of nursing practice.
Nurses are required to document timely and relevant information related to assessments, diagnoses or decisions about client status, plans, interventions and client outcomes.
Documentation serves three purposes:
Documentation practice standard sets out the requirements for paper or electronic documentation of client care.
If you use an electronic health record (EHR), understand that the same documentation requirements apply although there will be different strategies and methods to record information. An electronic signature, such as a unique password, code or personal identification number, links the information entered to that signature/individual. When using EHRs, it's important to maintain the security of your electronic signature and check your organization's policies on protecting confidentiality and security.
Additional considerations for electronic documentation include:
Thank you to the College of Nurses of Ontario for permission to adapt their content.