Documentation Standards

The Documentation Standards are developed and approved as outlined in Section 133 of the Health Professions Act (2000). All registrants providing nursing care must adhere to these standards. The purpose of these standards is to outline the professional regulatory expectations for registrants in producing clear, accurate and comprehensive accounts of client care within any practice setting.

Documentation is a required and essential part of care. It is an integral part of the registrant’s practice; and an important tool that registrants use to ensure high-quality client care, regardless of the context of practice, or the format of documentation (paper-based or electronic). The quality of documentation reflects the standard of professional practice. All registrants must document the care they provide in accordance with the College of Registered Nurses of Alberta (CRNA) standards of practice, entry-level competencies, the Canadian Nurses Association (CNA) Code of Ethics for Registered Nurses (2017), and employer requirements.