• Apply at all times to all Registered Psychiatric Nurses regardless of client care settings
• Establishes that client confidentiality is established and upheld at all times
• Provide expectations of all registered members of the profession
• Enables sound decision making
• Supports effective communication between health care providers

DOCUMENTATION MEASURES FOR RPNs:

• Responsible and accountable for documenting on a health record the care they have personally provided to the client including informed consent from the client.
• Document all relevant information about clients in chronological order, in a clear, concise, factual, objective, timely and legible manner.
• Document at the time or immediately after care is provided. Delays affect the continuity of care, affect the ability to recall details and increase possibility of error.
• Documentation does not take place prior to care.
• Complete documentation includes signature of writer and title in a clear and legible manner, or initials if appropriate after each entry.
• Electronic entries are made only using own unique identifier (log-in, user name).
• Comprehensive, in-depth and frequent documentation is required for all clients who are acutely ill, high risk or have complex health/mental health problems.
• Document clinical decision making (assessment, diagnosis, planning, implementation and evaluation) including communication with other care providers including name and outcomes of decision.
• When providing services to groups of clients utilize agency service records or equivalent to document service provided and overall observations pertaining to that group.
• Record client specifics from the group on the individual client health record.
• Use only agency approved abbreviations.
• Access client health information only for purposes that are consistent with professional responsibilities
• Comply with the applicable privacy legislation and follow employer/agency policies regarding collection, use(includes access to) disclosure, retention and security of health information
• Obtain informed consent from the client to use and disclose information to others outside the circle of the health care team and in accordance with relevant legislation
• Document late entries clearly, indicating both the date and time of the later entry and the date and time of the actual event.
• Documentation errors should be corrected in a timely, honest and forthright manner and clearly shows the person making the alteration, the date and time, the original entry must also be included in the client care record.
• Self-employed RPNs are responsible for the ownership and access to health records and requirements arising through provincial and federal information management and privacy legislation. At all times  client files (electronic or paper)  must be properly secured and maintained to ensure client confidentiality