March 2016

Five things to know about

Whether on paper or electronically, nurses use documentation to communicate the nursing care they have provided to a client and monitor the client’s progress. This promotes continuity of care by allowing other members of the health care team to access the information.

We often receive questions from nurses who want to make sure their electronic documentation practice is meeting the College’s standard.  The following points highlight the things you should know about electronic documentation:

1) The Documentation practice standard applies to both electronic and paper documentation. Different practice settings use different systems to document client care. If you need additional direction, refer to your organizational policies. You should use your organizational policies together with the College’s standard.

2) You must keep confidential any password or information required to access the client health record. Do not share your password with anyone else.

3) If the electronic system is unavailable, you must ensure that information captured in temporary documents is entered in the electronic system when it becomes available again. To minimize the duplication of records, you should securely and confidentially destroy the temporary documents when they are no longer in use.

4) If an electronic system has technical difficulties and was not restored during your shift, a designated recorder may enter the information when the system becomes available again. In such cases, the designated recorder must sign their name in the entry and indicate the circumstances.

5) If you discover an aspect of your setting’s electronic documentation system that makes it impossible to meet the College’s standard, (for example, if it is not possible to retrieve corrected information) you should advocate for system changes that will allow you to document according to standard.

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