DOCUMENTATION
PRACTICE STATEMENT 10
Approved by Council: 11‐Feb‐05
The College of Licensed
Practical Nurses of Alberta
(CLPNA) is mandated by
government to regulate the
profession of Practical Nurses
in a manner that serves and
protects the public.
Accordingly the College
develops specific practice
statements relevant to the
Practical Nursing profession.
The purpose of a Practice
Statement is:
™ To provide LPNs,
employers and the public
with information and
clarity regarding the
scope of practice for
LPNs.
™ To help eliminate
misconceptions regarding
the scope of practice for
LPNs.
™ To assist employers with
utilizing LPNs more
effectively in the health
care system.
Licensed Practical Nurses are responsible to document the professional services
provided to clients in adherence with the policies of the employing agency.
Definition
Documentation ‐ Written communication that reflects client’s health,
wellbeing and continuity of care.
Purposes of Nursing Documentation
• Facilitate ongoing communication with all the client care providers.
• Promote excellence in nursing care by allowing nurses to assess
client’s progress, determine the effectiveness of interventions and
provide written direction to the care plan.
• Meet professional and legal standards.
• Provide valuable data for decisions related to risk management,
nursing research, and workforce resources.
Legal Implications
In the context of a nursing negligence issue, nursing documentation may
be used to refresh a nurse’s memory when required to give evidence.
The courts may use this information to reconstruct events, establish
timelines and to resolve conflicts in testimony. Nursing documentation
may also be entered as evidence at a trial; therefore it is vital that an
accurate record of client care is maintained.
Guidelines
Following are significant common guidelines to be used for safe effective
documentation:
• Legibly written in ink.
• Concise, accurate and truthful.
• Entered in a timely manner.
• Late entries must follow agency policy.
• Chronological order of time and date.
• Standard agency approved abbreviations and symbols.
• All elements of care provided are documented.
• Reflective of observation, not unfounded conclusion.
• Client focused and confidential.
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DOCUMENTATION
PRACTICE STATEMENT 10
Approved by Council: 11‐Feb‐05
The nurse should document only the care she/he provides except in an
emergency when the nurse may be designated to document care
provided by other regulated health professionals. Agency protocols must
be followed to ensure the accuracy of each documented entry.
Charting by Exception
Charting by exception is a shorthanded method of documentation, rather
than the absence of documentation. Facilities that use this form of
charting by exception must ensure assessment norms and standards of
care are explicit. Records of the difference and analysis of the reasons for
the differences are kept on the narrative notes which must reflect the
judgment and critical thinking of the nurse providing care.
Health record documents may include:
• Paper documents
• Computerized records (electronic)
• Audio or video tapes
• E‐mails
• Faxes
• Image
REFERENCES
Licensed Practical Nurses, Standards of Practice. (May 27, 2003).Edmonton, AB: College of Licensed
Practical Nurses of Alberta.
Alberta Regulation 2003, Health Professions Act, Licensed Practical Nurses Profession Regulation. (2003)
Edmonton, AB: Government of Alberta.
nd
Competency Profile for LPNs (2 Ed). (Sept.14, 2004). Edmonton, AB: College of Licensed Practical Nurses
of Alberta and Alberta Health and Wellness.
Nursing Documentation‐Standards. (Revised 2002). College of Nurses of Ontario.
Freedom of Information and Protection of Privacy. (2000). Freedom of Information and Protection of
Privacy Act. Government of Alberta.
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