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DB: Communication & Interpersonal DB-05: 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:          
  • 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:          
  • 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:          
  • 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:          
  • personal / advance directives
  • DB-05-38
  • guardianship / power of attorney
  • DB-05-39
  • trusteeship.
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