Documentation

Nurses must document the person’s own words what they have come to know about the meaning and experience of health to them. Nurses must realize, people have a right to review their health record to ensure documentation reflects their own words.
Documentation should include the person’s own words on the following aspects of health care and the delivery of services:

The name they prefer to be addressed by;
Their perceptions, knowledge, and understanding of their health history and current health and wellbeing (health literacy);
Their strengths, concerns and fears, and how they feel their illness has affected them and their life;
Their perceptions, desires, preferences, and expectations for their care;
Their priorities for care and services (what is most important to them right now);
Their thoughts and feelings about their ability to manage their own health, their self-identified strengths and whether they feel they need assistance;
Considerations for planning, coordinating, and implementing care (e.g., beliefs, culture, sexual orientation, religion, spirituality, etc.);
Who they wish to have involved in their health care (circle of careG) and the degree to which they wish them to be involved (roles and responsibilities for care); and
What information they asked for related to their health, how they would like to receive this information (e.g., written, verbal, visual, electronic, language levels, and other preferences), and when would they like to receive the information (timing).

Foundational

Person and Family Centred Care

Point of Care Resources

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