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UCQ

Nursing Charting and Documentation

Key Elements of Nursing Documentation

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.

According to Nova Scotia College of Nursing (2022), nurses need to document the following:

* 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.

Reference

Nova Scotia College of Nursing. (2022, January). Documentation for nurses.  https://cdn1.nscn.ca/sites/default/files/documents/resources/DocumentationGuidelines.pdf