Documentation

The 2017 jurisprudence learning module focused on documentation and record keeping. You can access this module by logging in to your online profile.

Principles of Documentation and Record Keeping

Documentation and record keeping are a vital part of registered nursing practice. Your documentation must provide all relevant facts and demonstrate evidence of the nursing process. Regardless of what format you use to document, quality documentation and record keeping are a part of meeting the practice expectations, which you can find on our resources page or at the bottom of this page.

Download our handbook: Documentation Guidelines for RNs 

Quality Documentation

Quality documentation means that the elements of the nursing process are evident in your documentation. Click here to download a printable documentation checklist to make sure you are meeting documentation requirements.

References

  • CNPS infoLAW. (2007). Quality documentation: Your best defense.
  • Potter, P. & Perry, A. (2009). Canadian Fundamentals of Nursing (4th ed.). Toronto, ON: Elsevier.

Resources

Canadian Nurses Protective Society (CNPS)

Practice & Standards Consultants

Telephone: 204-774-3477 ext. 301
Toll-free: 1-800-665-2027 ext. 301 (Manitoba only)
Fax: 204-775-6052
practice@crnm.mb.ca