Designated recorder and co-signing

Who Should Document Care?

The Documentation practice standard outlines that documentation must be completed by the individual who performed the action or observed the event. The exception is when there is a designated recorder. The standard also outlines that nurses do not co-sign documentation entries.

Here are key scenarios that illustrate this accountability:

Nursing students: Nurses do not co-sign documentation for care provided by nursing students or any other healthcare team members, including fellow nurses. Co-signing can blur accountability, as it’s unclear who provided which aspects of care. Each provider must document their own actions.
Duplicate assessments: Even if a nurse agrees with a previous assessment (e.g., from a colleague on an earlier shift), they must document their own assessment. This reflects their professional judgment and ensures continuity and clarity in the client’s health record.

What is a designated recorder?

A designated recorder is a person assigned to document clinical findings when it may not be possible for the nurse implementing the care to document. Organizational policies should support and guide the use of designated recorders to ensure accurate and timely documentation of care.

Below are some examples of practice settings where a designated recorder may document care provided by others, in alignment with the Documentation practice standard and employer policies and procedures.

Examples of designated recorder use in practice settings

Code blue or emergency situations
- During a resuscitation or medical emergency, one team member may be assigned to document all interventions, medications administered, and observations while others provide direct care.
Vaccination clinics or public health campaigns
- In high-volume settings, a designated recorder may document vaccine administration details while nurses focus on client care and education.

How is co-signing a documentation different from witnessing a documentation?

It’s important to distinguish between co-signing a person’s documentation entry and applying a second signature to witness an event or verify accuracy.


Co-signing a documentation entry	This involves two nurses signing off on a single note. – Co-signing blurs accountability and creates confusion about who was responsible for providing the care.
Witness signature in documentation	In this case, the second signature is not about documenting care; it is about witnessing a process. Understanding this distinction helps maintain clarity, accountability, and alignment with professional standards and organizational policies. Examples of witnessing include: Medication waste: Two nurses may sign to confirm the proper disposal of a controlled substance. Patient’s belongings: two nursing signatures may be required to verify the accuracy of a documented list of belongings

Co-signing a documentation entry

This involves two nurses signing off on a single note. – Co-signing blurs accountability and creates confusion about who was responsible for providing the care.

Witness signature in documentation

In this case, the second signature is not about documenting care; it is about witnessing a process. Understanding this distinction helps maintain clarity, accountability, and alignment with professional standards and organizational policies.

Examples of witnessing include:

Medication waste: Two nurses may sign to confirm the proper disposal of a controlled substance.
Patient’s belongings: two nursing signatures may be required to verify the accuracy of a documented list of belongings