This open access textbook is intended to guide best practices of documentation in the nursing profession. This resource is designed for students in undergraduate nursing programs, and addresses principles of documentation, legislation associated with documentation, methods and systems of documentation, and key trends in the future of documentation. Incorporated into this resource is legislation and practice standards specific to the province of Ontario, Canada.
About the Authors
Jennifer Lapum, PhD, MN, BScN, RN, Professor, Daphne Cockwell School of Nursing, Toronto Metropolitan University (formerly named Ryerson University), Toronto, Ontario, Canada
Oona St-Amant, PhD, MScN, BScN, RN, Associate Professor, Daphne Cockwell School of Nursing, Toronto Metropolitan University (formerly named Ryerson University), Toronto, Ontario, Canada
Charlene Ronquillo, MSN, RN, Assistant Professor, University of British Columbia, Canada
Michelle Hughes, MEd, BScN, RN, Professor, School of Community and Health Studies, Centennial College, Toronto, Ontario, Canada
Joy Garmaise-Yee, DNP, MN, RN, Professor, Sally Horsfall Eaton School of Nursing, George Brown College, Toronto, Ontario, Canada
Contact person
Dr. Jennifer L. Lapum
jlapum@torontomu.ca, 416-979-5000 ex. 556316
350 Victoria St., Toronto, ON, M5B 2K3
Toronto Metropolitan University (formerly named Ryerson University)
@7024thpatient
Note to Educators Using this Resource
We encourage you to use this resource and would love to hear if you have integrated some or all of it into your curriculum. If you are using it in your course, please consider notifying Dr. Lapum and include the course/program and the number of students.
Acknowledgments
Linn Clark, Editor, Toronto, Ontario, Canada
Frances Dimaranan, BScN student, Daphne Cockwell School of Nursing, Ryerson University, Toronto, Ontario, Canada
Ann Ludbrook, Copyright and Scholarly Engagement Librarian, Ryerson University, Toronto, Ontario, Canada
Mahidhar Pemasani, BScN student, Daphne Cockwell School of Nursing, Ryerson University, Toronto, Ontario, Canada
Nada Savicevic, Interactive Design, Educational Developer, Centre for Excellence in Learning and Teaching, Ryerson University, Toronto, Ontario, Canada
Sally Wilson, Web Services Librarian, Ryerson University, Toronto, Ontario, Canada
Customization
This textbook is licensed under a Creative Commons Attribution 4.0 International (CC BY-NC) license except where otherwise noted, which means that you are free to: https://pressbooks.library.ryerson.ca/documentation/
SHARE – copy and redistribute the material in any medium or format.
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The licensor cannot revoke these freedoms as long as you follow the license terms.
UNDER THE FOLLOWING TERMS:
Attribution: You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.
No additional restrictions: You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.
Notice: You do not have to comply with the license for elements of the material in the public domain or where your use is permitted by an applicable exception or limitation.
No warranties are given. The license may not give you all of the permissions necessary for your intended use. For example, other rights such as publicity, privacy, or moral rights may limit how you use the material.
