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Documentation

Nurses document timely and appropriate reports of assessments, diagnoses or decisions about client status, plans, interventions and client outcomes.

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:

  1. facilitates communication
  2. promotes safe and appropriate nursing care
  3. meets professional and legal standards.

The Documentation practice standard sets out the requirements for paper or electronic documentation of client care.

 Documenting in electronic health records

Additional considerations for electronic documentation

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:

  1. Create a strong password and change it frequently
  2. Do not share your password or other access information with anyone
  3. Log off when you leave the terminal or finish using the system
  4. Make every effort to protect your monitor/screen from being seen while you are working
  5. Report unauthorized use of an electronic signature or access to the appropriate person in your agency

Thank you to the College of Nurses of Ontario for permission to adapt their content.

 Meeting the professional standards through documentation

Standard 1: Maintains standards of nursing practice and professional conduct determined by CRNBC

Examples:

  • Document all relevant data.
  • Indicate accountability and responsibility by adding their signature and appropriate title to each entry you make in a client record.
  • Assess your documentation practice and undertake activities to improve practice and meet learning goals.
  • Advocate for and /or help to develop agency policies and practices for electronic documentation that are clear and consistent with CRNBC standards.
Standard 2: Consistently applies knowledge, skills and judgment in nursing practice.

Examples:

  • Understands the purpose of and reasons for accurate and effective documentation.
  • Documents client status, using verifiable information, in terminology used in the practice setting.
  • Documents client assessments, decisions about client status, plans, interventions and client outcomes consistent with the CRNBC Standards of Practice.
  • Individualizes care plans to address the needs and wishes of individual clients.
Standard 3: Provides nursing services and works with others to provide health care services in the best interest of the clients.

Examples:

  • Uses documentation to share knowledge about clients with other nurses and health care professionals.
  • Regularly updates kardex information and ensures that relevant client care information is captured in the permanent health record.
  • Documents relevant communication with the client's family or substitute decision-maker
  • Keeps the plan of care clear, current and useful.
  • Participates in changes to documentation practices that improve client care and nursing practice.
Standard 4: Understands, upholds and promotes the ethical standards of the nursing profession

Examples:

  • Safeguards the security of printed or electronically displayed and stored information.
  • Disposes of confidential information in a manner that preserves confidentiality (e.g., shredding).
  • Clearly signs and accurately represents self with respect to name, title and role.
  • Acts as an advocate to protect and promote clients' rights to confidentiality and access to information.
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