We want to hear from you! The Learning Commons team is striving to provide the best possible learning experience for our students, staff, and faculty. Please share your valuable feedback and suggestions.
In general, nurses' charts and documents should provide
• client needs and goals;
• actions of the nurse as required by a needs assessment; and
• outcomes and/or evaluations of actions.
All data that is considered clinically significant should be recorded.
* plan of care
* admission, transfer, transport, and discharge information
* client education, including method of teaching, materials used, and who was involved
* serious reportable incidents (SRES) that put clients or nurses at risk
* medication administration
* verbal orders and telephone orders
* text and mail orders
* collaboration with other health care professionals
* date, time, signature, and designation
College of Registered Nurses of Manitoba have a downloadable checklist you can use to make sure you are meeting documentation requirements.
