Skip to Main Content
It looks like you're using Internet Explorer 11 or older. This website works best with modern browsers such as the latest versions of Chrome, Firefox, Safari, and Edge. If you continue with this browser, you may see unexpected results.
UCQ

Nursing Charting and Documentation

Legal Requirements of 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 defencehttps://cnps.ca/article/infolaw-qualitydocumentation/