Standards of Practice for Registered Nurses
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.
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 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.
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
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:
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:
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.
Canadian Nurses Protective Society (CNPS)
Telephone: 204-774-3477 ext. 301
Toll-free: 1-800-665-2027 ext. 301 (Manitoba only)