​​​​​Meeting standards through documentation​

Regardless of setting or designation, nurses demonstrate professional responsibility and accountability by ensuring documentation is:

• Timely. Document at​ the time of care or as soon as possible afterward.
• Accurate and factual. Document what you saw, heard, did, and communicated—not assumptions or guesses.
• Complete. Include assessments, interventions, communication, and outcomes.
• Respectful and culturally safe. Use the client's words when appropriate. Avoid stereotypes or judgmental language.
• Secure. Follow privacy, confidentiality, and electronic health record (EHR) access requirements.

• Professional. Sign each entry with your regulated title and unique identifier.
  

Ref​lection: Your documentation habits

Think about your last shift. Did your documentation clearly sho​w:

• ​The client's condition
  
• Your clinical reasoning
  
• What you did and why
  
• Who you communicated with
  

• The client's preferences ​​and choices
  

If someone else had to take over care, would they know what happened?

What documentation looks like in practice

Below are short scenarios with examples of what to document and why it matters.

Scenario 1: Client declines a treatment

You approach a client to administer a prescribed treatment. They appear uneasy and say: “I'm not comfortable with this today. I reacted badly last time."

You explore their concerns, assess their condition, and discuss options. You then notify the prescriber and agree on a plan with the client. 

​​What do you include in your documentation? ​

• “Client ref​used treatment."
• The client's reasons (in their own words if appropriate)
• Your assessment
• Who you notified and what they said
• The outcome and follow-up plan
• Your assumptions about why the client refused

Correc​t approach

• Client's choice and reasons (using respectful, culturally safe language)
• Your assessment and interventions
• Who you notified and their response

• Outcome and​ plan

Do not include:

• Personal opinions
• Your assumptions
• Judgmental statements

​

Why this matters (standards in action)

• Supports informed decision-making (Consent practice standard)
• Uses respectful, non-stigmatizing language (Indigenous Cultural Safety, Cultural Humility, and Anit-racism practice standard)
• Reflects clear communication and continuity of care (Documentation practice standard)
• Includes name/title of provider notified (Use of Title practice standard)
• Protects client information (Privacy & Confidentiality practice standard)

Scenario 2: Sudden change in client condition

A client suddenly becomes pale and short of breath. You assess quickly, obtain vital signs, provide immediate interventions, and call the physician. 

​When do you document this?

A. At the end of your shift.

Too late. Waiting creates risk of gaps and inaccuracies.

B. Only if the client stabilizes.

Unsafe. Documentation must reflect changes as they happen.

C. When your manager asks.

Incorrect. Documentation is not optional or manager-dependent.

D. As soon as reasonably possible after providing care.

Yes. Documentation is timely and reflect assessments and interventions as close as possible to when they occur.

What do you include in your docu​mentation?

• Assessment findings

• What another nurse “thinks happened"
• Vital signs
• What you think the diagnosis is
• Your interventions
• Client response
• Provider notified (name/title/time)
• Outcome or ongoing plan

Correct approach

Include the facts:

• What you observed
• What you did
• How the client responded

• Who you notifie​d and when

Do not include:

• Speculation
• Unverified information
• Diagnoses outside nursing scope​
  

​

Why this matters (standards in action)

• Timely, factual documentation supports safe care (Documentation practice standard)
• Protects sensitive information (Privacy & Confidentiality practice standard)
• Accurate identification of team members supports accountability (Use of Title practice standard)
• Bias-free, respectful language supports culturally safe care (Indigenous Cultural Safety, Cultural Humility, and Anit-racism practice standard)

Better d​ocumentation: Before and after examples

Example 1

B​efore: “Client upset."

After: “Client pacing and tearful. Stated, 'I feel overwhelmed and can't sleep.' Explored coping strategies; provided support. Vitals obtained. Follow-up plan discussed. Notified provider (NP Chan) at 11:40."

Example 2

Before: “Refused care."

After: “Client said, 'I don't want the injection today. My arm was swollen for days.' Assessed site; discussed risks/benefits. Client chose to delay. Prescriber notified (Dr. Lee, 14:05). Plan updated."

Example 3

Before: “MD aware."

After: “Notified Dr. Singh at 09:20; provided SBAR. Dr. Singh advised monitoring q30 min and rechecking vitals. Plan implemented."

Qui​ck ​​decision check: Is this important to document?

Ask yourself three quick questions:

1. Did I see something important?
2. Did I do something important?
3. Did I say or hear something important about care?

If yes to any → document it.

This tool supports but does not replace the standards and your clinical judgment.

Electronic hea​lth records, digital documentation, and AI

The same requirements apply whether you are charting on paper or in an electronic health record (EHR). Digital communication (secure messaging, email, EHR chat) that informs care must be captured in the client record. If it informs care, it belongs in the record, not just in a message thread.

Nurses:

• Maintain the security of their electronic signature and password
• Log off when not actively charting
• Prevent unauthorized viewing

• Report​ inappropri​​ate access​
  

When using AI tools:

• Use AI responsibly and in accordance with employer policies
• Employer approval and policy must be in place
• Nurses remain accountable for verifying all entries generated with AI assistance

​Self-employed nurses

If you are self-employed, you are responsible for maintaining your own client records in alignment with:

• BCCNM bylaws and standards
• Provincial legislation (e.g., PIPA)

• Secure sto​​rage and retention requirements

Clients have the right to access their records and request corrections.

FA​Q​​s​

How much charting is enough?

Enough to give a clear, accurate picture of the client's status, what you did, how they responded, and any communication. Nurses carry out more comprehensive, in-depth, and frequent documentation when clients are acutely ill, high-risk, or have complex health needs. Follow employer policies and seek guidance if you are unsure.

Should I document consultations with other providers?

Yes, if their direction affects client care. Include the provider's name, title, and their response. Document the reason for consultation, actions taken, and outcomes. 

What about NPs in primary care networks?

NPs must create and maintain complete client records, including assessments, decisions, orders, and care plans. They must also follow B.C. legislation such as FIPPA, PIPA, and the Limitation Act, along with employer policies.

NPs need to clarify whether they or the clinic/health authority is the custodian/trustee of client records. Custodians are legally responsible for privacy, access, and record retention. BCCNM bylaws outline retention requirements. Employers may have additional requirements.

If the NP works in a shared EMR or group practice, a data-sharing agreement should outline ownership, custody, access, and what happens if the NP relocates, retires, or dies. If unclear, NPs should seek advice from CNPS or their legal counsel.

For questions about legal obligations, NPs should contact the Canadian Nurses Protective Society (CNPS) or seek independent legal advice.

Resources

BCCNM learning resources

• Documentation in Nursing Practice module​​​
  

External resources

• Canadian Nurses Protective Society (CNPS)
• Institute for Safe Medication Practices Canada – List of Dangerous Abbreviations, Symbols, and Dose Designations
  

​​​Need help or support?​

For further guidance on understanding and applying the standards of practice, contact our team by completing the Standards Support intake form.​