Documentation

This year’s jurisprudence learning module focuses on documentation and record keeping. You can access this module by logging in to your member profile.

In preparation for coming under The Regulated Health Professions Act (RHPA), this module was developed using the future nursing regulations and bylaws and standards of practice for registered nurses and registered nurses on the extended register. We’ll post a draft of these updated documents on this webpage when they become available.

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 Standards of Practice for Registered Nurses and the Standards of Practice for Registered Nurses on the Extended Practice Register.

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.

Why do we document?

  • Documentation facilitates the sharing of client information between health-care providers. Clear, complete and accurate documentation ensures that everyone involved in a client’s care, including the client, has access to the information they need to plan and evaluate client care.
  • Documentation facilitates meeting our legislative requirements. Documentation is a valuable method of demonstrating that you have applied nursing knowledge, skill and judgment within a nurse-client relationship. 
  • Documentation promotes quality improvement and can be used to help evaluate quality of service and appropriateness of care through chart audits and performance reviews.
  • Documentation promotes and improves research. Health records serve as a valuable and major source of data for new health-care knowledge.
  • Documentation demonstrates legal proof that health care was provided. Generally speaking, if it was not documented, it was not done.

How often should I document?

Documentation should be a regular and frequent part of your nursing practice. It is very important that you document soon after you provide care to support accurate recall of information and to communicate effectively with other members of the health-care team.

“For accuracy, the courts have stressed the importance of recording at the time of an event or as close to it as prudently possible. Unnecessary delay between the occurrence of the event and the recording may result in a court refusing to admit the record as proof of the truth and questioning the credibility of the information or witness.” - CNPS

Documenting in Higher Risk Situations

It is especially important to document more often during times when a client is at increased risk of harm or there is a higher degree of risk involved in the care provided. Additional documentation may be required when:

  • a client is newly admitted
  • a client is being transferred between units or facilities
  • a client is being discharged to self-care
  • a client's status changes or doesn't improve as expected
  • other members of the health-care team have been notified (or re-notified) of a change or lack of change in a client's condition
  • an unanticipated, unexpected, or unusual event occurs with a client or family member
  • a client is engaging in risk-taking behavior
  • a client refuses care or withdraws consent

How does documentation differ for electronic records?

The basic principles of quality documentation still apply when using electronic records. However, electronic records carry higher risks around privacy and confidentiality as they are easier to retrieve than paper copies. It is important to check your organization's policies on protecting confidentiality when using electronic records. A few special considerations include:

  • Do not log in for someone else.
  • Create a strong password and change it frequently.
  • Do not share your password with anyone.
  • Log off when you are finished using the system.
  • Make every effort to protect your monitor/screen from being seen while you are working.
  • If your electronic signature is automatic, confirm that your full name is spelled correctly and your professional designation is included.

Maintaining Safe and Secure Records

Storing health information is an important part of maintaining safe and secure records. Client records must be kept for at least 10 years following the date of the last entry on the record. Records for minors must be kept for at least 10 years after the minor turns 18 years of age. 

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