Nursing Charting and Documentation

Nursing documentation can be used in legal proceeding.

According the Canadian Nurses Protective Society (CPNS; 2022), documentation is legally important to show

• communication between health-care providers;
• continuity of care;
• legislative and professional requirements are being met;
• accountability for the professional practice;
• commitment to providing safe, effective and ethical care; and
• legal proof of health care provided.

CPNS (2022) notes that proper charting is important for patient care as well as to prevent or defend legal proceedings.  They suggest nurses

•    be familiar with any guiding documents from their institution and follow standard practice;
•    review any applicable policies, guidelines, procedures, and/or processes put in place by their health institution to guide the nurse’s practice             in relation to documentation;
•    document at the time of care or as soon as possible after providing care;
•    document often, carefully, and thoroughly, especially during transitional periods, such as handovers, shift change, patient discharge, and                 during critical periods of patient care; and
•    avoid preparing personal notes outside the chart.

Reference
Canadian Nurses Protective Society. (2020, October). InfoLaw: Quality documentation: Your best defence. https://cnps.ca/article/infolaw-qualitydocumentation/