Nursing Documentation for Adult and Child Health Policy

Kia ora! 

The purpose of this policy is to ensure that Auckland District Health Board's (Auckland DHB) expectations are met regarding nursing documentation for all patients (excluding Mental Health and Addictions) within Auckland DHB.


The clinical record holds entries by all healthcare providers contributing to the care of the patient. Nursing documentation contributes to this, providing a record of the care provided and evaluation of that care, including use of the associated clinical-record charts and forms.


The expectations of this course are that you will: 

  • read the policy 
  • access any resource page(s) on Hippo 
  • review your documentation against the standards expected - use the education tool as a guide 
  • complete the self-evaluation section  - this acknowledges that you have read the policy/guideline and have had an opportunity to discuss any questions you have with your preceptor/nurse educator or manager