Dear CNO,
My home unit is on a surgical floor. I recently floated to the emergency department to provide additional coverage. While I was in there, I was assigned to document the care that other health care providers, including nurses, provided to stabilize a critically injured patient. Do the nurses who provided this care also need to document what they did, or is my documentation enough?
When you’re involved in a medical emergency, documentation may not be the first thing on your mind. However, clear, complete and accurate documentation is an essential part of safe nursing practice. Nurses’ documentation responsibilities are informed by CNO’s practice standards, legislation and employer policies.
CNO’s Documentation practice standard states that nurses are accountable for documenting their own assessments, communications and actions. In most situations, you document the care you personally provide rather than care provided by someone else. One exception is when a designated recorder has been assigned.
A designated recorder documents on behalf of the care team when others are unable to document at the time. During a resuscitation or medical emergency, for example, one team member may be assigned to document all interventions, medications administered and observations while the rest of the team focuses on the patient.
In the scenario you described, your documentation may be enough if you were formally acting as the designated recorder and followed your organization’s policies and procedures. Each organization decides when and how this role is used, so the expectations should be clearly defined in its policies.
If you’re unsure what was expected in this situation, speak with your clinical educator or a member of your leadership team. They can explain how the designated recorder role works in your practice setting and whether any further documentation is needed.
CNO can provide guidance only on nurses’ documentation accountabilities. Other regulated health care professionals, such as physicians and respiratory therapists, must follow the requirements of their own regulatory body.
Lastly, situations like the one you described can be stressful and emotionally challenging. If this experience is affecting you, take a moment to pause and reflect on what you need to support your mental well-being. CNO’s Mental Health Resources for Nurses provides a list of trusted resources, including crisis lines, peer support and counselling services for nurses.
Thank you for reaching out with your question,
Emily Marcogliese, RN, PhD
Advanced Practice Consultant, Practice Quality