Yes. Nurses are required to document the care they provide accurately and in a timely, factual, complete and confidential manner. All documentation and record keeping must adhere to the documentation and privacy requirements as defined by their regulatory body, employer policy and provincial legislation. These documentation expectations are the same across all practice settings.
Documentation is not separate from care and is not optional. It is an integral part of the nurse’s practice, and an important tool that nurses use to ensure high-quality client care. Nurses document holistic, patient focused-care including relevant components of the nursing process:
Documentation is evidence that care has been provided and is necessary for: