Documents and Reports

No.	Competency Item	NAC	DEV	COM	DTE	EXC
DB-05-01	Demonstrate ability to apply critical thinking and clinical judgment when documenting and reporting all areas of care and intervention.
DB-05-02	Demonstrate ability to apply legal protocols throughout practice.
DB-05-03	Demonstrate understanding of accountability and responsibility to ensure accurate and concise documenting and reporting.
DB-05-04	Demonstrate understanding of the legalities and agency policy regarding documenting and reporting.
DB-05-05	Demonstrate knowledge and ability to document and report client care following agency channels of communication.
	Demonstrate knowledge of the purpose and proper use of various documentation tools and techniques such as:
DB-05-06	assignment sheet
DB-05-07	audit
DB-05-08	change of shift report
DB-05-09	chart
DB-05-10	checklist
DB-05-11	electronic records
DB-05-12	flow sheet
DB-05-13	incident / occurrence reports
DB-05-14	interdisciplinary progress notes
DB-05-15	narrative notes
DB-05-16	nurse's notes
DB-05-17	nursing care plan
DB-05-18	various interdisciplinary reports.
	Demonstrate ability to follow appropriate documentation procedures to ensure accurate, complete, and quality documentation for purposes of:
DB-05-19	accreditation
DB-05-20	audit
DB-05-21	communication of information regarding client and care
DB-05-22	education
DB-05-23	legal record of care
DB-05-24	planning client care
DB-05-25	quality assurance monitoring
DB-05-26	research
DB-05-27	risk management
DB-05-28	statistics.
	Demonstrate knowledge and ability to document promptly and regularly by using appropriate:
DB-05-29	medical terminology
DB-05-30	approved abbreviations
DB-05-31	metric system
DB-05-32	24 hour clock
DB-05-33	subjective and objective data.
DB-05-34	Demonstrate ability to follow agency policy and procedure and universally accepted guidelines for documenting and reporting client information.
DB-05-35	Demonstrate ability to provide pertinent client information to the nursing team to ensure continuity of care.
DB-05-36	Demonstrate the knowledge and ability to adhere to the various Legislation affecting the documentation, reporting, and sharing of client information.
	Demonstrate knowledge of legal protocol regarding specific areas such as:
DB-05-37	personal / advance directives
DB-05-38	guardianship / power of attorney
DB-05-39	trusteeship.