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Documentation

Clear, comprehensive and accurate documentation is an integral part of safe and effective nursing practice. Documentation provides a record of the judgment and critical thinking used in professional practice, and provides an account of the nurse’s unique contribution to health care.

The Documentation practice standard describes the expectations for nurses in all practice settings and for all forms of documentation

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Chapter 1 - An Overview

 

Chapter 2 - Communication

 

Chapter 3 - Accountability

 

Chapter 4 - Security

Test Yourself

 Test youself

Page last reviewed December 21, 2020