Registered Psychiatric Nurses, Partnering with People

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Charting and Documentation

The Registered Psychiatric Nurses Association of Saskatchewan believes that proper charting/documentation establishes and supports the nursing process. Charting/documentation provides a chronological record of events involving the client from admission to discharge from the health care facility/system for the purpose of:

  1. Communicating Client Health Information
  2. Providing Continuity of Care
  3. Demonstrating Professional Accountability
  4. Providing a Base for Quality Improvement
  5. Facilitating Research

It is the responsibility of the Registered Psychiatric Nurses Association of Saskatchewan, through the Nursing Education Program Approval, Registration and Disciplinary processes, to ensure that Registered Psychiatric Nurses are adequately prepared and maintain the professional and legal standards of charting/documentation.

The standards of charting/documentation are guided by but not limited to the following principles:

  1. Chart/document all pertinent nursing actions and observations.
  2. Chart/document at the time of event or as close as prudently possible.
  3. Charting/documenting should be done by the RPN who has first-hand knowledge of events or who performed the nursing action.
  4. Avoid the use of abbreviations. If their use is necessary, use only those accepted abbreviations as set out in agency policy.
  5. Charting/documentation should be more comprehensive, in depth and frequent for very ill or high risk clients and new admissions.

The Registered Psychiatric Nurses Association of Saskatchewan believes that it is important that facilities employing Registered Psychiatric Nurses have policies ensuring that the professional and legal standards of charting/documentation are being met. Employers need to provide adequate orientation and ongoing support related to their agencies’ charting/documentation system (including computerization). It is the responsibility of employers to set staffing quotas and assignments to allow adequate time for charting/documentation.

References:

  1. Canadian Nurses Protective Society. Quality Documentation: Your Best Defence. InfoLaw (Vol. l, No. 1, May, 1992). Ottawa, Ont.
  2. Saskatchewan Union of Nurses. Position Statement on Nursing Documentation/Charting.

Adopted April, 1996.
Approved by Council
September 1996

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