I am a nurse. - College & Association of Registered Nurses of Alberta

8
Documentation is not separate from care and it is not optional.
It is an integral part of RN practice and an important tool that
RNs use to ensure high-quality client care. Quality documentation
demonstrates the application of current knowledge, clinical skills
and judgment. Documentation is the permanent record that
demonstrates the nurse’s accountability and gives credit to nurses
for their professional practice. When documentation is incomplete
or inaccurate it brings into question whether the care was completed.
When done well, nursing documentation is a valuable tool to support
effective communication between providers and continuity of care
within and across settings and reflects that the RN has competently
applied their knowledge to assess, plan, intervene and evaluate
patient outcomes. Comprehensive and accurate documentation
provides a record of astute nursing insights, reflects the excellence
of holistic nursing care and provides a health-care record of the
professional and personal support that RNs provide every day
to clients and their families.
DISSEMINATION OF CDRC FINDINGS
CDRC hopes that sharing their findings will encourage RNs to:
• reflect on their current practice
• have an open discussion about practice issues
• identify areas in which change is needed in their practice setting
• cooperatively problem solve to ensure that steps are taken to
minimize the occurrence of unprofessional or unskilled practice
in the future
CDRC believes it is important that the trends identified in the conduct
decisions are widely shared with RNs so that they have insight on
those factors that can prevent or interfere with a supportive practice
environment and a culture of quality within a practice setting.
This information provides an opportunity for RNs to reflect on
these trends and recognize their responsibility in ensuring that
their nursing practice and conduct meet the standards of the
profession and the policies relevant in the practice setting. RN
Alberta RN April 2008 Volume 64 No 4 www.nurses.ab.ca
CARNA NURSING CONSULTANTS HELP
RNS ADDRESS PRACTICE CONCERNS
RNs can talk confidentially with a CARNA nursing
consultant – Policy and Practice, who can support
them in meeting professional standards by helping
them to:
• understand the application of legislation,
regulations, standards, guidelines and position
statements to their practice
• foster evidence-informed decisions on
issues with the potential to affect nursing
practice, policy and education in nursing
and health care
• use the “Addressing Unsafe Practice
Situations” framework included as appendix 2
in the CARNA Nursing Practice Standards.
The framework provides a process for RNs
to clearly identify a concern and address
the concern before it leads to a situation of
imminent harm or unprofessional practice by:
identifying their problems or questions
considering a range of viable options
using evidence to support practice
selecting actions to resolve their questions
or concerns
CONTACT INFO
To reach a CARNA nursing consultant
call 780.451.0043 or toll free in Canada
1.800.252.9392
CARNA Education Sessions for RNs
Attend the session on Addressing Unsafe Practice Situations.
See pages 21-22 for details.
Visit www.nurses.ab.ca