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Nursing Standards > Learning Centre > Online Learning Modules

Last modified: October 12, 2006

Nursing Standards

Overview

Compendium of Standards

Professional Standards

Documents list

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Overview

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Practice Line

Documentation

Documentation is an integral part of safe and effective nursing practice. Clear, comprehensive and accurate documentation is a record of the judgment and critical thinking used in professional practice, and provides an account of the nurse' unique contribution to health care. The Documentation practice standard describes the expectations for documentation, and applies to all nurses in direct practice, regardless of the method of documentation, or how it is stored.

Objectives

1. Identify the expectations of all nurses when documenting client care.
2. Describe the purpose and legislative requirements of documenation and retaining health records.
3. Identify the nurse’s role when maintaining and documenting in electronic health records.

Chapters

• Purpose of Documentation   //   Notes
• Meeting the Standards   //   Notes
• Electronic Health Records   //   Notes
• Other Considerations   //   Notes
  (Charting by exception, documenting telephone nursing care, accessing health records)

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Additional Resources

• Documentation - practice standard (#41001)
• Confidentiality and Privacy: Personal Health Information - practice standard (#41069)
• Telepractice - practice guideline (#41041)