Documentation

Documentation is used to effectively communicate all care provided to the patient or student. A written account of all care needs to be recorded. The delegating RN will provide you with the forms that you are expected to use to record care. The records should be stored in a safe and private location.

You may be asked to send copies of the records to the delegating RN. The nurse will review the forms to ensure that appropriate care is provided.

Discuss with your delegating RN the best way to contact the nurse to report any concerns or changes in the patient’s or student’s condition.

General Rules for Recording

• Make sure each documentation form is clearly marked with the person’s name and other identifying information (e.g. room number, student ID number)
• Always record in ink
• Include the date and time for every entry
• Make sure writing is readable and neat
• Use correct spelling and punctuation
• Do not use ditto marks
• Sign all entries with your name and title

If you make a mistake in the documentation record do not erase or use correction fluid; instead draw a line through the mistake and initial above the line.