Documentation, Revised 2008
Table of Contents
Introduction Why Document? The Inter-relationships that support clients through documentation Standard Statements and Indicators Communication Accountability Security Appendix A: Supporting Documentation Practices Appendix B: Nursing Documentation Legislation References Appendix C: Electronic Documentation Resources Suggested Reading List 3 3 5 6 6 7 8 9 10 11 11
OuR mISSION is to protect the public’s right to quality nursing services by providing leadership to the nursing profession in self-regulation. OuR vISION is excellence in nursing practice everywhere in Ontario.
Documentation, Revised 2008 ISBN 1-897308-56-6
Pub. No. 41001
Copyright © College of Nurses of Ontario, 2009. Commercial or for-profit redistribution of this document in part or in whole is prohibited except with the written consent of CNO. This document may be reproduced in part or in whole for personal or educational use without permission, provided that: • Due diligence is exercised in ensuring the accuracy of the materials reproduced; • CNO is identified as the source; and • The reproduction is not represented as an official version of the materials reproduced, nor as having been made in affiliation with, or with the endorsement of, CNO. First published April 1996 as Nursing Documentation Standards (ISBN 1-894557-31-X) Reprinted January 2000, October 2000, Revised June 2002 (ISBN 1-894557-33-6), Reprinted December 2002, Revised for Web June 2003, Reprinted January 2000, December 2005, May 2008 (ISBN 1-894557-40-9). Revised in December 2008 as Documentation, Revised 2008. Reprinted June 2009. Additional copies of this booklet may be obtained by contacting CNO’s Customer Service Centre at 416 928-0900 or toll-free in Ontario at 1 800 387-5526. College of Nurses of Ontario 101 Davenport Rd. Toronto, ON M5R 3P1 www.cno.org Ce fascicule existe en français sous le titre : Tenue de dossiers, édition révisée de 2008, no 51001
PR ACTICE STAndARd
Nursing standards are expectations that contribute to public protection. They inform nurses of their accountabilities and the public of what to expect of nurses. Standards apply to all nurses regardless of their roles, job description or areas of practice. — College of Nurses of Ontario
documentation, and Appendix C references general resources on electronic documentation.
Nursing documentation is an important component of nursing practice and the interprofessional documentation that occurs within the client1 health record. Documentation — whether paper, electronic, audio or visual — is used to monitor a client’s progress and communicate with other care providers. It also reflects the nursing care that is provided to a client. This practice standard explains the regulatory and legislative requirements for nursing documentation. To help nurses2 understand and apply the standards to their individual practice, the content is divided into three standard statements that describe broad practice principles. Each statement is followed by corresponding indicators that outline a nurse’s accountability when documenting and provide guidance on applying the standard statements to a particular practice environment. To further support nurses in applying the standards, the document also includes appendices containing important supplementary information and a list of suggested readings. Appendix A provides strategies for nursing professionals — including nurses, researchers, educators and nurse employers — to support quality documentation practices in their work settings. Appendix B includes a sampling of provincial and federal legislation governing nursing
Nursing documentation: reflects the client’s perspective, identifies the caregiver and promotes continuity of care by allowing other partners in care to access the information; communicates to all health care providers the plan of care,3 the...