This document outlines the criteria and performance standards for demonstrating competency in documentation. It lists 6 performance criteria based on ANMC National Competency Standards for Registered Nurses from 2005. These criteria assess the student's ability to identify indications for documentation, use appropriate terminology, provide relevant and accurate content, adhere to legal requirements, effectively use standard forms, and link theory to practice. The student is rated on a scale of competent, requires supervision, or requires development for each criterion by the clinical facilitator. Space is also provided for compulsory reflection by the student and comments by the clinical facilitator on the student's overall performance.

1. Clinical ski lls com petency
COMPETENCT Docu mentation
DEMONSTRATES: The ability to accurately record information
about a patient in a timely manner
CRITERIA
C:Competent
S=Requires Superuision
D=Requires Development
PERFORMANCE CRITERIA (numbers indicate ANMC Nationa[
Competency Standards for the Registered Af*rse, ?OO5)
C s D
1 ldentifies indications for docurnentation in the patient's
chartlrecord {2.5. S.2i
2. Uses appropriate medical terminology and approved
abbreviation and acronyms ( l .1. 2.2, 2.6,4.2',
3- Content is relevant and accurate
(r.2, 1.3, 2.?,2.5,2.6, 4.4,5.3, 6.1, r 0.2)
4. Adheres to legal requirements (l .1, 1.2)
5. Dernonstrates ability to effectively use the facilities' standard
forms {1 .1, I.2, 10.2)
6. Demonstrates an ability to link theory to practice
(3.2,4.1,4.21
*Source - Tollefson, J.2A12 "Clinical h/schomotor Skills Assessment Tools for
5" Edition - CENGAGE Learning (pp66-68).
Nurses
Compulsory Reflection by Student: (Please refer to Levett-Jons and Burgeois text IlrE Clinicat Placement ppg+
102 - model for reflection)
tra,t r^ii+{^ vaAicua &n<}t r.l4tu&r
;tkd lo.{ ntxA,at...t . {, A.;A SPoC
on a separate sheet if nexssary
initia$How would you rate your overall performance whilst urdertaking this clinical activity? (Please
Unsatisfacto.y E Satisfaaory 1-l eood l_l Excellent Gl
Comments by RN:
Canli*ue on a sheet if
How would you rate the overall performance of this student during this clinica[ activity? (prease in*iar) :
unsatisfactory I Satisfactory l-l cooc l-l Excetlent W
student Name: {fiease prrnfl RANSU 3H(ESTnAs;nn,
UNE - HSNS 206 Clinical Record Eook - Clinical Skiils Competencies - Revis€d Edition November 20 l 4 3l

2. Clinical skills com petencf/
COMPETENCY: Documentation
DEMONSTRATES: The ability to accurately record information
about a patient in a timely manner
CRITERIA i,.
C=Competent
S=Requires Supervision
D=Requires Dev
PERFORMANCE CRITERIA {numbers indicate At'$lc National
Competency Sundards for the Registered Narse, 2fi)5)
C s D
I. ldentifies indications for documentation in the patient's
chart/record (2.5, 9.2)
t0
2. Uses appropriate medical terminology and approved
abbreviation and acronyms (1 -'l .2.2,2.6,4.21 AD
3. Content is relevant and accurate
(1.2, I -3, 2.2, 2.5, 2.6, 4.4, 5.3, 6.1, 10,2) 60
4- Adheres to legal requirements (1 .1, 'l .2) 6fr
5- Demonstrates ability to effectively use the fucilities' stardard
forms (1.1, 'l
.2, 10.2)
4,0
6. Demonstrates an ability to link theory to practice
(3.2, 4.1, 4.21
a0
"Source - Tollefton, J. 20I2 "Clini s Assessment Tools for Nurses
56 Edition - CENGACE Learning (pp66-68).
COmpulSOry RefbCtiOn by StUdent: (Please refe to LevdtJones and Burg*is iext The C{mical Ptar,e,meltf ppw>*
I02 -modd for reflection)
N/w Lter^t-
+'l^A ,,.Figrnt-e i1^ ;-ir.- "o
tos
cl^N.t Iqr/- i& loalavrc* c.lnart
bcu.lPi iscisn 3lv t-a.j-Q ntan
c-9^e* al$ta,vs
Cq*inue os a sepamte sheef rf necessary
How would you'rate;your ovsrall perfarmancewhilst undertaking IE clinical activity? (Please initiaD
Unqatisfactory [], satisfactory E eooo tl Excetlent E
Comments by RN:
Continae on a separate sfieef ff
Student Name: {pteaseprint} RftUf U Dae: 16/ov/tS
i44"a
, t( -aP. rfGlinical facilitator (RN): 6pease pna lisn: t'n
NB .Completion of this comped;rcy is refidired to satisfa€tolily complete this placement'
UNE - HSNS 263 Clinical Record Book - Clinical Skills Competencies - Revi:ed Edition March 2Ol 5

3. Clinical skills competency
CO MPETEN CY: Docu mentation
DEMONSTRATES: The ability to accurately record information
about a patient in a timely manner
RN please place your initials in the appropriate column
CRITERIA
C=Competent
S=Requires Superuision
D=Requires Development
"Source - T 20I2 "Clinical nrnotor S ls Assessment Tools Nurses"
PERFORMANCE CRITERIA (numbers indicate ANMC National
Campetency Standards for the Registered Narse, 2O05)
1. ldentifies indications for documentation in the patient's
chart/record (2.5, 9.21
2. Uses appropriate medical terrninology and approved
abbreviation and acronyms (1.1. 2.2, ?.6, 4.2)
3. Content is relevant and accurate
(l .2, 1 .3, 2.2,2.5,2.6, 4.4, s.3, 6.1, 't 0.2)
4. Adheres to legal requirements (l "1 ,
'l
.2)
5. Demonstrates ability to effectively use the facilities' standard
forms {l .i, 1.2, 1 0.2)
6. Demonstrates an ability to link theory to practice
{3.2, 4.1, 4.2)
5'fr Edition - CENCACE Learning (pp66-68).
Compulsory Reflection by Studentl (Please refer to Levett-Jones and Burgeois text Iire Clinica! Ptacemeni pp95
102 - model for rdlection)
r"rt^l Lp- , [I,,Jr n"ts&;.^j-
C i*q<-!qAe$ er"t'( v'^4alz^-{,o{od<-ta 0ilte- be-0a*arr' c-t-tt
'rr"tX-O & t/-t' iAA rt t^-t tn "t-r.-s ,^ett
Cantinue an a sheet if
How would you rate your overall performance whilst undertaking this clinical activifif (Please initial)
unsatisfactory t satisfactory l*l Gooa l-l Excettent 1{2{l
Continue on a separafe sheef if necessary
How would you rate the overall performance of this student during this clinical activity? (Pte;lse initial)
] Exceltent WUnsatisfactory Satisfactory Good
Student Name: (ptease print) Rort.. SL.r.r'ta+t ,'.< Sign:
-Clinicalfacititator (RN): (prease ,,*, l, {€N}Aftfl/ sign=
Date:
oate:30'4'lS
NB Completion of this competency is required to satisfactorily complete this placement.
UNE - HLTH 3i 0/5i0 Clinical Record Book - Clinical Skills Competencies - Revised EditionJune 20i 5 24
,(

4. COMPETENCY: Docu mentation
DEMONSTRATES: The ability to accurately
about a patient in a timely manner
record information
CRITERIA:
C:Competent
S=Requires Su pervision
D=Req u ires Development
Clinical com pete ncy
, J, ools for Nursesran, E. 20.i6 "Clinical Pyschomotor Skills: Assessment
6'i Edition - CaNCAGE Learning (pp88-9'I).
PERFORMANCI CRITERIA (numbers indicate ANMC National
Campetency Standayds for the Registered Nurse,?AQS) fr)s D
I ldenlifies indications for
chart/record (2.5, 9.2)
d0cum entation 1n the patient's /1 l
ul2. Uses appropriate medical terminology and approved
abbreviatlon and acronyms (.l.1. 2.2, 2.6, 4.2)
,il
l
Contenl is relevant and accurate
(1 2, 'i
.3, 2.2,2.1,2.6, 4.4,5.3, 6.',t ,
'.i
0.2) I4. Adheres to legal requirements (l.,l, l.Z)
A
5. Demonstrates ability to effectively xse the facilities' standard
forms(l.l, i.2, I0.2) A
6. Demonstrates an ability ro link theory to practice
(?) a1 d)
-)
,#. i
-nt T &H or6'al T
Compulsory Refleciion by Studeni: (Please referto LevetlJones and Burgeois text Ihe Ctinicat Placementppg}-
'102
- model for reflection)
$tt. <r.-&i q,r.t*'s YO/'r.t
cAA-a, P
L (rl3eE ,*"r.-qd-i d,X kaArrrri
Continue on a separate sheef if necessary
you rate your overall p",fo*rrr"" *niirt
saiisfactory l--l Satisfactory l=_l
undertaking
Good
clinical activity? (Please initial)this
Comments by RN:
ki^-,
,flv'a 6-..<--t+ /^ Jr-^4
'tg1'
A^-e- tv'-"2 ,
on a separate sheet if necessary
Student Name: {ptease print) furr"J * Shreatha.sign: 4
Clinicat facilitator {*N}; lprease },r,, d; . laMr/ra t/ Sig;
ort", tvfov[16
Dal*: qfl&
NB Completion of this competency is required to satisfactorirft complete this
UNE - HSNS 364 Clinical Record Book - Clinical Skills Competencies - Revised Edition January 2016
placement.
24

5. Clinical skills competency
COMPETENCY: Docu mentation
DEMONSTRATES: The ability to accurately record information
about a patient in a timely manner
RN please place your initials in the appropriate column
CRITERIA:
C=Competent
S=Requires Supervision
D:Req u ires Deve lopment
PERFORMANCE CRITERIA(numbers indicate NMBA National
Competency Standards for the Registered Nurse)
C S D
I . ldentifies indications for documentation in the patient's
chart/record (2.5,9.2)
,il./-t
z/--
2. Uses appropriate medical terminology and approved
abbreviation and acronyms (l .1. 2.2, 2.6,4.2)
)-,
/:r'=
'
3. Provides relevant and accurate content
(1.2, 1.3, 2.2, 2.5, 2.6, 4.4, 5.3, 6.1, 10.2)
/) .-
/rt-'t,// t'
4. Adheres to legal requirements (1 .l , I .2)
/-,
.:'
5. Demonstrates ability to effectively use the facilities' standard
forms (l .1, 1.2, 10.2)
-:o,/-._
6. Demonstrates the ability to link theory to practice
(3.2,4.1,4.2)
//- /
,/,/ /
*Source - Tollefson. l, & Hillman, E. 2016 "Clinical Pyschomotor ls: Assessment Tools for Nurses
6'h Edition - CENCACE Learning (pp88-91).
Compulsory Reflection by Student: (Please referto LevetLJones and Burgeois text The Clinical Placement-model
for reflection)
'.f. -1 t{ r-t r tLf.1 c--rr,u( , '-t , 7 pr- cL ) c c rl'd,tk ( i.i a t <.lV.t.( <-, .t-
,r- ,1E-,:.r-.--.t'"',,.-(-ittfl-l r-1'.vr l- i.-lr-1 .i^!.C-t *,"vug-,".[-.",i ,.-t'(,!..r1 ,,'-LL('
,L.I..L.1]t'.,"-t,'G 'i. &...( r* f u.e .1 . ,r"-4tt'.1i.t i C-'L-,: 1-q,ttli.. o['r- 714::=tti,
,.r,Ual r t;r ,,-it.( i ,J ii^;t*! cif:'[:,i'LPl'-l,r-i-L .
'r.vt€:rf.rrzrt t-E-rr;-tiu'r--i{ctir c.'i,4
Ir* - ,.-;.1-i ( ,ri ,-;L, r..;1
itiiiion,u""b*:;'ri)Jrirn""""ru,y
How would you rate your overall performance whilst undertaking this clinical activity? (Please initial)
Unsatisfactory E satisfactory l-l cooo I-l Excetlent lT!
Comments by RN: f
,J
- ({(, , )1,:') /
"i ,/ ,. -1/1 I rl (i ,..J.1ct>t{ 7* ./t
s
,l::, f I * r7/.2 (r,r.i( (/aJ-y /c /{(tfi
i, ,, ,
/i
'i !. {.,', /'
Continue on a separate sheet if nece
How would you rate the overall performance of this student during this clinical activity? (Please initial)i
Unsatisfactory E satisfactory l-l cooa @ Excellent l-l
Student Name: (ptease print) sisn, ;f-,:+#.'., pr1"' I ) /r
q
/rt
Clinical facilitator (RN): lprease
NB Completion of this competency is required to satisfactorily complete this placement.
UNE -HSNS 368 Clinical Record Book - Clinical Skills Competencies - Revised EditionJune 2016
rJ -!:L^, it,.rt"i'."t
23

6. e0tilffTEltlfY: 3*el lnentati*n
recor* inf*rmati+r
e*a?=*,t.*
C=C*rr*peaent
S:iequires S*perui:ion
D=Requiras ilev t
BEfttOl.lSTfA?€5: The *biliry tc accurateg
aba*t a p*tient in
=
tirn*ly mailrer
fli-ira* :kill: eompetenry
Cliric*l &cilitatry {Rtl}: frmaserra* 9" $ig*:liB eamtrletian sf this .*r:rpete3ey i*-risrir;A rf ;Elsilcta
t!llLfitt
pERfO*i{ANet ea,fE$A {nua:bers indieate A!4t$ Na*anr,t
C*y'**et**cy 5t*ndards {os, t*ze R*.gistered ##rse, 2€0S} { 5 il
:. ldertifies i::dicarions for doEumentati+n *n :lte pati*.:t,r
ehart/reeor* i2.5, 9.:: ho
2. lJ.:es *pgrcariate xedir=l terminolqy ara alpiaved
abbreviati*n a*d aer*r:pls {l.1. 2.!,'2.6, +.Zi 9o
3. Cort€nt is relev*nt a*d aee$rate
{1,3, '1,3, 2"?,2,5,3,S, 4.4, 5.3, 5_t, }0,=} &D
4" Adheres :a l*gal reqxirertent= {I "I, i.?}
Lo
5. femoRsrrales ablli:y to effeetively ure the faetlil!=' rtardard
lorms {1.:, L:, I *":} ,ry
6. Demcnsara:es a* aliiitS:o linl al*€cry ac pra{tiee
(=-2, 4":, 4.:: &0
J. ealZ *Clinical
fosehomotor Skills As es*msnt Tc*ls
56 E*itisll - ff${A6f t*ar*tng {r*S6€8i.
C*rnprl**ry Refi*ctio* by $tudent {?kae e rdar *o t*vs*i-Jrrc* ar* *urg*ais texl I*e *ti:rr# F€*ee*: errt??*-1E - :nod** for rellac:io*]
A .0,."d 614 0bs M e&i c*^,
S3 r sv't :3 baJ,to,,rrix- drra],b C^A.L pLa'n CTu,aA LL.l-k
rW)+X,vYaa e-rnelr"twr<t* Ot^$- tAtO].Jr^& CaJLz . I. UtJ-c.-A
C**ti*u* ** a sl*elrf r:e=ess*4r
l**$rwsuld y*u rate yoar *verall p*ri*ra*ncaxhil=t ur:de*aking !ili* eii*ieal a**uiq6 lpleaee iri**t;
lJr:satlsfa*ary [} Safi*fa*tary []f eooC ffiJ Exeel**t fA
*qm.fi**ts by *l{:
qg r r^.dt docurneA cat,on d*rl
C*rci
S*r*::sa a* a,=ep*ra{a sfieel ff *e+ss**ry
H*w stuld y*u r*la t** averall perf*nna**e *i !*is **u***t {uring thie *li*ical ad:v::y? {pE*= htral} :
unsatisfact*ry - Eati*fact*ry l]_} so* 17] Exccle* l,J
$krd*ri ffarn*; {ptcaa*sriztt} (AN[9 €l_1LES1114 Sign:
U*E - Hst{l 2!€ fli:rieal Eectrd Eanir f lixir:l tlcili< fnm**rnn.i5. ea*;:*;r !**ia* arr,.-*i-* a*, ,
t , lbhzllt