Practical Nursing: Documentation

We developed the Documentation Guidelines for Nurses to help LPNs, RNs, and NPs meet their standards of practice related to documentation. Nursing documentation is a vital component of safe, ethical, and effective nursing practice. This document describes nurses’ accountability and the expectations for documentation in all practice settings, regardless of the documentation method or storage.

This practice scenario has been developed to help nurses understand how they should sign their nursing documentation on a client’s health record.

Our Documentation Online Education is designed to help you better understand our Documentation Guidelines for Nurses. Nursing documentation is a vital component of safe, ethical and effective nursing practice, regardless of the context of practice. Nursing documentation is required to be compliant with standards of practice and other legal requirements. This module is a resource to help you to meet your accountabilities related to nursing documentation.