REx-PN Management of Care: Confidentiality, Information Security and documentation
Learn purposeful access to health information and clear records of assessment, action, response and follow-up.
- Access only the information needed for your authorised care role.
- Document promptly, accurately and objectively.
- Correct a record through the approved process while preserving its audit trail.
Sources checked 6 October 2026.
Who may access a client's information?
Care-related access must have an authorised purpose. Curiosity about a neighbour, colleague or public figure is not a care reason. Share the information necessary for the intended care purpose through approved channels, and follow the organisation's consent and privacy rules. A colleague's professional title does not make every disclosure appropriate.
What belongs in a nursing record?
Record the relevant assessment, decisions, interventions, the client's response and follow-up. Include dates, times and your identification through the approved system. Describe observations and attribute a client's words clearly. Avoid unsupported judgments about character or intent. CNO's revised Documentation standard took effect on 1 February 2026.
How are late entries and errors handled?
Use the approved late-entry and correction process. Keep the original record and audit trail intact; do not erase or disguise an error or backdate an entry. Distinguish when the event occurred from when you entered it. Do not document another person's work as though you performed it.
What changes with electronic records and messaging?
Protect your credentials, close unattended records and use approved communication systems. Personal messaging or social media does not become an acceptable disclosure channel merely because identifiers are omitted. If a privacy incident occurs, follow reporting and containment procedures promptly. A record supports continuity; it does not replace urgent direct communication.