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.

NEW! In preparation for the RHPA coming into force on May 31, 2018, we have created a handbook called Documentation Guidelines for Registered Nurses. You can download your copy below:

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