Ins and Outs of Documentation for Canada

Green Clock Hours: 0.50

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.



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Course Description

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.



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