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UCQ

Nursing Charting and Documentation

Getting Started

Why is correct charting and documentation important for nursing students and nurses?

The College of Nurses of Ontario (2019) states that documentation is an important component of a nurses' work.

Proper charting and documentation

•    allow all health care partners access to care information;
•    communicate an entire plan of care, history, and interventions;
•    help nurses provide safe, ethical, and accountable care;
•    show that nurses have followed professional standards;
•    provide data for research; 
•    allow nurses to review, evaluate, and reflect on care; and
•    can be used for the assessment and evaluation of nursing interventions.


Most importantly: It's part of a nurse's job that a nurse is legally obligated to do correctly.

Reference
College of Ontario Nurses. (2019). Documentation, revised 2008. https://cno.org/globalassets/docs/prac/41001_documentation.pdf