Can team members document for one another?

Documentation is an essential element of care.  Every regulated health professional is required to document the care they have provided in accordance with the standards of practice of their profession.  Each professional should be aware of the requirements of their own regulator and ensure that they meet these requirements.

Only in specific circumstances should a health care provider document for another member of the team, and in those situations, it must be clear who had the first-hand knowledge of the event, who performed the activity, and who recorded the activity. Examples of documentation on behalf of a team include a flow sheet or code blue record.

Ultimately, when a team member documents on behalf of the team, each team member remains individually accountable for the care they provide and to ensure the record of that care is accurate and complete.