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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
Introduction
Nursing documentation is an important component
of nursing practice and the interprofessional
documentation that occurs within the client
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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 nurses
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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
documentation, and Appendix C references general
resources on electronic documentation.
Why Document?
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,
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the assessment, the interventions
necessary based on the client’s history and the
effectiveness of those interventions;
■
is an integral component of interprofessional
documentation within the client record;
■
demonstrates the nurse’s commitment to
providing safe, effective and ethical care by
showing accountability for professional practice
and the care the client receives, and transferring
knowledge about the client’s health history; and
■
demonstrates that the nurse has applied within
the therapeutic nurse-client relationship
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the
nursing knowledge, skill and judgment required
by professional standards regulations.
Whether documenting for individual clients, or for
provide a clear picture of:
■
the needs or goals of the client or group;
■
the nurse’s actions based on the needs assessment;
and
■
the outcomes and evaluation of those actions.
Data from documentation has many purposes:
■
It can be used to evaluate professional practice as
part of quality improvement processes.
■
It can be used to determine the care and services a
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In this document, a client may be an individual, family, group or community.
2
In this document, nurse refers to Registered Practical Nurse (RPN), Registered Nurse (RN) and Nurse Practitioner (NP).
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In this document, the term plan of care may refer to treatment plan, care plan, care map, service plan, case management, mental health
assessment plan, resident assessment forms, or other terms organizations use.
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For more information, refer to the College’s Therapeutic Nurse-Client Relationship, Revised 2006 practice standard at
www.cno.org/publications.
College of Nurses of Ontario Practice Standard: Documentation, Revised 2008