The documentation standard is necessary in the nursing practice. The standards communicate the accountabilities of nurses and what the public expect of them. Documentation can be presented in form of paper, electronic, audio or visual. It is used to monitor the client record progress and communicates with other care personnel. It also tells the nursing care that is given to the client.
Documentation is necessary for many reasons. It provides a clear picture of the needs of the client or group. It also shows the nurse’s action and outcomes as well as evaluation of the actions. The data obtained from documentation can be used to evaluate nursing practice for quality improvement purposes. It determines the services the clients require. The nurses usually review the information to help them determine the knowledge gaps. Documentation can also be used to assess the nursing interventions provided and client outcomes. Nurses are supposed to prepare and maintain records as professionals. They should ensure that their documents are clear as per the institution’s practice standards. However, failure to adhere to the practice standards, amounts professional misconduct under Nursing Act, 1991.
There are various interrelationships that help nurses to discharge quality services. The college of Nurses of Ontario support nurses through fact sheets, practice standards and guidelines. They help them discharge safe, effective and ethical care to their clients. Through documentation, nursing organizations support them with policies, protocols and decision making tools. They are also accountable to the professional standards that the institution prefers.
Standard statements provide the principles that guide nursing profession. There are three standard statements that describe accountabilities when documenting. They include communication, accountability and security. In addition, the indicators apply the standard statements in practice environment.
Communication enables the nurses to provide a comprehensive picture of the client. The nurses ensure that they provide the client needs, interventions and results in a systematic manner. The professional nurse meets the standard by providing a complete record of nursing care. A nurse is required to document necessary communication with client relatives. They must ensure that the planned care is current and relevant to meet the client’s needs. In addition, nurses should document informed consent and clear policies as per the College’s practice standards.
Accountability enables the nurses to ensure that their documentation is clear, relevant and complete. This is achieved by documenting in a timely manner. Documentation is completed by the person who performed the action. Also, a professional nurse should advocate for clear documentation policies and protocols in line with the institution standards.
Nurses protect the health information of clients. They maintain confidentiality and act in accordance with information retention and destruction policies. A nurse meets the standard by ensuring the client information is captured in the permanent record. It should be mandatory to adhere to policies, standards and legislation related to confidentiality. Nonetheless, nurses should facilitate the rights of the clients.
In supporting the standards, the document also provides supplementary information. First, it provides strategies for nursing professionals that support quality documentation practices. Secondly, it provides a sampling of provincial and federal legislation that guides the nursing profession. Thirdly, it also contains references of general resources on electronic documentation.