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.