Nursing documentation is a critical component in high-quality patient care and safe, effective nursing practice that is legally and ethically sound (College of Registered Nurses of Nova Scotia,2012).

Moreover, nursing documentation is a vital component of safe, ethical and effective nursing practice, regardless of the context of practice or whether the documentation is paper-based or electronic.

This document is intended to provide registered nurses (RNs) with guidelines for professional accountability in documentation and to describe the expectations for nursing documentation in all practice settings, regardless of the method or storage of that documentation.

The document intends to assist the registered nurse to meet their standards of practice related to documentation (College of Registered Nurses of Nova Scotia,2012).
Although different documentation systems and technology may be used throughout the province, quality nursing documentation is expected in every area of care or service delivery and in every setting.

Nurses must be familiar with and follow agencies’ documentation policies, standards and protocols. It is recommended that the Nursing Documentation Program Guidelines for Registered Nurses serve as a basis for the development of agencies’ policies on nursing documentation. If there are no agency policies in place related to documentation, it is the professional nurse’s responsibility to advocate for the creation of policy to support nursing practice. If, despite advocating for the creation of policies, there are still no documentation policies in place, professional nurses need to use their Standards of Practice, these guidelines and professional judgment to guide practice.

This one-day program is designed to introduce a unified comprehensive approach for RNs and is based on a critical thinking approach, and it consists of a one-day workshop.