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.
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.
Packed with colorful images and clear-as-day guidance, this friendly reference guides you through meeting documentation requirements, working with electronic medical records systems, complying with legal requirements, following care planning guidelines, and more.