Peer Review

This open access textbook is intended to guide best practices of documentation in the nursing profession. This resource is designed for students in undergraduate nursing programs, and addresses principles of documentation, legislation associated with documentation, methods and systems of documentation, and key trends in the future of documentation. Incorporated into this resource is legislation and practice standards specific to the province of Ontario, Canada.

Open (Access) Textbook

• Lecture
• Homework
• Team activities
• Individual activities

• Internet access with web browser

Users will:

• Define documentation.
• Explain the reasons for documentation.
• Apply the principles of documentation.
• Interpret elements related to privacy, confidentiality, and security.
• Demonstrate use of documentation methods.
• Describe documentation systems.
• Practice critical thinking in documentation.
• Identify key trends likely to influence the future of documentation.

• College Lower Division, College Upper Division, Graduate School, Professional

• Basic understanding of healthcare and healthcare terminology