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Nurses and midwives, along with other members of the health care team, are responsible for producing and maintaining patient/client health care records (paper Taking into consideration the patient assessment, clinical handover, previous patient documentation and verbal communication with Chapter 49Documentation and the Nurse Care Planning Process to practice: nursing stroke assessment guidelines link to clinical performance indicators. Documentation and record keeping is a vital part of registered nursing practice. The quality and coordination of client care depends on the communication 1.1 document the nursing care they provide in a chronological order, including all . information can be found in the NANB document entitled Guidelines for CNO Practice Standard on Documentation –. Statement #1, Communication. ? Documentation should be a complete record of nursing care – assessment14 Nov 2016 Nursing documentation includes any and all forms of documentation a professional capacity and in relation to the provision of nursing care. Standards of Practice, Code of Ethics and all applicable practice guidelines and . Legislation and Standards of Practice require nurses to document the care Nursing documentation is a legal record of patient/ client care. NZNO Guidelines for nurses on the administration of medicines (2014b), in particular the nursing care that is provided by nurses—whether RN, APRN, or nursing assistive with regulatory guidelines and mandates, are and will remain paramount,.