Module 1: Professional Accountability and Prescribing

Lesson 4

Documentation and record keeping exercise

Nurses are expected to maintain quality nursing documentation in every area of care or service delivery. The CDSA and NCPR are the legislation specifically addressing records of controlled drugs. There are numerous legislative regulations that address nursing documentation both federally and jurisdictionally. Most colleges and associations have created documentation guidelines for registered nurses to assist in maintaining this responsibility. Review documentation requirements by visiting your college’s or association’s website. Browse through the documentation standards guidelines and notice the legislative regulations applicable to documentation.