Ins and Outs of Documentation for Canada

Ins and Outs of Documentation for Canada 

Long-term care homes maintain various types of resident-specific information in order to detail residents’ health status and care. This information can include observations and facts about residents’ personal, medical, and social well-being. There are 6 essential elements when documenting information that help maintain the integrity of information in residents’ health records. These elements help ensure that information entered into residents’ health records is clear, concise, and accurate. As a nurse in a long-term care home, you are required to document information in residents’ health records. It is vital that you know the importance of objective, consistent, and accurate documentation. It is also important to be knowledgeable of documentation best practices.


Hours: 0.50


Certificates provided by accrediting body (0 Match)

Course Details

Course Code: REL-PAC-CA-IAOC
Hours: 0.5
Type: Online Course
Content Expiration Date: 8/31/2024
Learning Objectives:
Describe the need to document objectively.
Explain the 6 key elements of documentation.
Discuss why care plans must be individualized and accurate.


Section 1: Introduction

About This Course

Learning Objectives

Section 2: Documentation Best Practices

The Basics of Documentation

Documenting Factual and Objective information

The 6 Essential Elements of Documentation

What Care Was Provided?

Who Received the Care?

Who Provided the Care?

When Was the Care Provided?

Why Was the Care Provided?

The Resident’s Response to the Care Provided?

Mitigate Duplication

Importance of Care Plans and Proper Documentation


Section 3: Conclusion


Course Contributor




Instructor: Lynda Welch, RN

Lynda Welch is a registered nurse with an extensive career history in long-term care management. She provides general administrative and clinical nursing consultative services to staff in long-term care homes. Lynda is also a legal nurse consultant. Her understanding of operational and clinical issues related to long term care, combined with her ability to read and interpret government standards and legislation, provides plaintiff, defense and labour lawyers with an objective, evidence-based opinion related to relevant standards of care.

Disclosure: Lynda Welch, RN has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Relias will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Course Delivery Method and Format
Asynchronous/Online Distance Learning; please see certificate details for specifics on delivery format.
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