Introduction to Documentation

Documentation refers to paper or electronic record keeping about a client’s state of health and their care. Paper record keeping involves using a pen to write in the client’s chart, while electronic record keeping involves typing directly into a client’s chart using a computerized device. A paper chart is typically in a three-ring binder or folder and is dedicated to a specific client.

These forms of record keeping are typically referred to using the interchangeable terms the “client’s chart” or the “client’s health record.”

The nurse should document all phases of the nursing process, including:

• Assessments, history, and observations of the client’s health status including both normal and abnormal findings.

• Diagnostics, planning, and interventions including care, treatment, services, and health teaching.

• Evaluations of the care, treatment, and services provided, noting how the client responded, and any necessary follow-up.

The components of documentation included in the client’s chart will depend on the area of care and institution. For example, a nurse working on a cardiac unit will document different findings than a nurse working on a labour and delivery unit, and a client’s chart will also vary by institution, such as across hospitals, out-patient clinics, primary care settings, and long-term care facilities.

The next section explores the reasons for documentation.