On This Page
Documenting for unregulated care providers
Our UCPs do not have access to electronic records. My manager has asked that I document the care a UCP provides. Should I do this?
CNO recommends that documentation be completed by the individual who performed the action or observed the event, as it can blur accountability of who provided what care. However, CNO acknowledges that some settings do not provide UCPs with access to electronic records and this becomes the nurse’s accountability. When documenting the care a UCP provides, it is important for the nurse to clearly identify the UCP performing the assessment and/or intervention. Nurses must also follow the standards as outlined in CNO’s Documentation practice standard.
Employers are responsible for developing clear documentation policies and procedures that best meet patient needs. Documentation policies should be in the interest of patient safety and in alignment with relevant legislation and the standards of practice.
