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DOCUMENTATION IN NURSING

MAHMOOD AHMED

Introduction:
Professional Standards are necessarily required for nurses to document timely and accurate reports of
relevant observations, including conclusions drawn from those observations. Documentation is any
written or electronically generated information about a client that describes the care or service provided
to that client. The College of Registered Nurses of British Columbia Practice Standard Documentation
sets out the requirements related to documentation and nurse practice and should be used in conjunction
with this practice support publication. The term documentation is used in this publication means any
written or electronically generated information about a client that describes the care or service provided
to that client. “Client” refers to individuals, families, groups, populations or entire communities who
require nursing expertise. It allows nurses and other care providers to communicate about the care
provided. It promotes good nursing care and supports nurses to meet professional and legal standards of
Documentation.
Health records may be paper documents or electronic documents, such as electronic medical
records, faxes, e-mails, audio-video tapes and images. Through documentation, nurses communicate
their observations, decisions, actions and outcomes of these actions for clients. Documentation is an
accurate account of what occurred and when it occurred. Nurses may document information pertaining
to individual clients or groups of clients. Individual Clients when caring for an individual client (which
may include the client’s family), the nurse’s documentation provides a clear picture of the status of the
client, the actions of the nurse, and the client’s outcomes. Nursing documentation clearly describes: an
assessment of the client’s health status, nursing interventions carried out, and the impact of these
interventions on client outcomes; a Care plan or Health plan reflects the needs and goats of the client;
needed changes to the care plan; information reported to a physician or other health care provider and
when appropriate, that provider’s response; and advocacy undertaken by the nurse on behalf of the
client.
Documentation in the Intensive Therapy Unit (ITU) is carried out for a number of reasons. It ensures
continuity of care and provides up-to-date patient status; it fulfils hospital policies which furnish the
legal aspects of ‘duty of care’. Bavin (1988) and Fracassi (1987) both argue that the intensive care
nurse has to be highly skilled today due to technological advances and complex care of the critically ill
patients. Also the documentation and care required are complex and time consuming.
Documentation focuses on patient data in relation to the nursing and medical observations and
therapies in the Critical units and the use of a ‘Plow Chart’ is to improve the present documentation
system. It provides continuous monitoring and in most cases provides criteria for admission to the unit
and these criteria may include such conditions as multi-trauma, drug overdose, post-operative major
vascular surgery, cardio-pulmonary arrest and sepsis. The current process of documentation involves
numerous and separate charts.

Definitions of Documentation:
• Documentation is any written or electronically generated information about a client that describes
the care or service to the client
• Documentation is the key - If it is not written it did not happen
• The term documentation” is used in this publication to mean any written or electronically generated
information about a client that describes the care or service provided to that client. “Client” refers to
individuals, families, groups, populations or entire communities who require nursing expertise
• Documentation is the written evidence of the interactions between and among health care
professionals, patients and their families, and health care organizations; the administration
procedures, treatments, and patient education; and the results or patient’s responses to them
• Documentation includes all aspects of the nursing process as well as the contributions of all other
health team members to the patient’s care
• Nursing Documentation is that part of the clinical record written by nurses and is the total written
information concerning patient’s health status, nursing needs, nursing care, and response to nursing
care. Key components of nursing documentation includes assessments, nursing diagnoses, planned
care, nursing interventions, patient teaching, patient out come, and interdisciplinary communication
• Nursing Documentation comprises of all written and/or computerized recordings of relevant data
made by nurses to document care given or to communicate information relevant to the care of a
particular client/patient. Other supporting documentation includes:
 Policies/Procedures/Protocols
 Rosters
 Incident Reports
 Performance Appraisals/Assessments
 Personnel Files
 Computer Generated Data
 Dependency Studies
 Research Data
 Documents required for health finding purposes
• Temporary media, such as audio taped or video taped handovers, should not be considered as a
substitute for full and proper documentation in client/patient records
Purposes of Documentations:
• Professional accountability
• Professional responsibility
• Quality assurance
• Patient client’s teaching
• Education
• Research
• Reimbursement
• Prevention of missing something in care
• Prevention doubling or duplication in care
• Monitoring
• Communicate information accurately, effectively and in a timely fashion
• Financial billing
• Assessment
• Auditing
• Legal record
• Legal and practice standards and protection
• Who else depends on the information in the record?
o Medical records and Coding department
o Billing and finance
o Internal and External quality monitoring
o Insurance companies and Attorneys
o Secondary users of varying sophistication.
 Legal and ethical issues
 What may be obvious at the time needs to be explicitly stated for later reference (hours,
days, years later)
 Need to reflect complexity of medical services provided
 Language does matter - Accuracy and specificity are essential

Reason for Documentation:


• To facilitate communication: Through documentation, nurses communicate to other nurses and
care providers their assessments about the status of clients, and nursing interventions that are
carried out the results. Documentation of this information increases the likelihood that the client
will receive consistent and informed care or service. Accurate documentation decreases the
potential for miscommunication and errors. However documentation is most often done by nurses
and care providers, there are situations where client(s) and family (ies) may document observations
and / or care provided in order to communicate with members of the health care team
• To promote good Nursing care: Documentation encourages nurses to assess client progress and
determine which interventions are effective and ineffective, and identify and document changes to
the plan of care as needed. Documentation can be a valuable source of data for making decisions
about finding and resource management as well as facilitating nursing research, all of which have
the potential to improve the quality of nursing practice and client care. Individual nurses can use
outcome information or information from a critical incident to reflect on their practice and to make
necessary changes based on evidence
• To meet professional and legal standards: Documentation is a valuable method for demonstrating
that, within the nurse-client relationship, the nurse has applied nursing knowledge, skills and
judgment according to professional standards. The nurse’s documentation may be used as evidence
in legal proceedings such as lawsuits, coroners’ inquests, and disciplinary hearings through
professional regulatory bodies. In a court of law, the client’s health record serves as the legal record
of the care or service provided. Nursing care and the documentation of that care will be measured
according to the standard of a reasonable and prudent nurse with similar education and experience
in a similar situation.
Key Components of Nursing documentation
Component Description
Assessments Include assessments and reassessments that are ongoing. Routine
frequency is determined by health care organization policy

Identify patient needs or Includes documentation on a problem list or a care plan and
nursing diagnoses sometimes on an assessment. Health care organizations are
increasingly using standardized diagnoses

Planned care Include a separate care plan or p care documentation on progress


notes or separate guidelines for care
Revisions of planned care Includes reasons for change, supporting evidence, and agreement
from patient or family for the revised plan of care

Nursing Interventions Includes patient observations, treatment interventions, teaching,


clinical judgment& Document on flow sheets and progress notes

Patient teaching Includes learning needs, teaching plan content, mode of instruction,
(who and what were taught), patient response and comprehension
Patient out come Includes the following:
 Patient progress toward goals (expected outcomes)
 Patient response to tests, treatments, nursing intervention
 Patient, family response to significant events
 Questions, statements, complaints voiced by patient or family

Interdisciplinary Includes communication with physician and other disciplines and


communication & their outcomes. Mostly this occurs in form of referral in multi
team conferences problems diagnosed clients

Document Information
Face sheet Lists biographical data (name, date of birth, address, phone number,
social security number, marital status, employment, race, gender,
religion, closest relative); insurance coverage, allergies, attending
physician, admitting medical diagnosis, assigned diagnosis-related
group, statement of whether the client has an advance directive or
not.
Consent form Include the following:
 V Admit: permission given to institution and physician to treat
 V Surgery: explains the reason for the operation in lay terms; the
risks for complications; and the client’s level of understanding
 V Blood transfusion: grants permission to administrator blood or
blood products
 V Medico legal or Non- Medico legal: grants permission to
physician and nurses to deal accordingly
 V Various others: grant permission to participate in research,
have photograph taken, and to know HIV status

Medical history and Details results of the client’s initial history and physical assessment as
Physical performed by the physician and nurses
examination

Physician’s order Outlines medical orders to admit; the treatment plan and complete
sheet medication information

Physician progress Delineates physician’s evaluation of the client’s response to treatment;


notes may also contain the progress recording of other practitioners, e.g.,
dietary or social services
Consultation sheet Initiated by the physician to request the evaluation or services of other
practitioners. It is also called referral or exerts opinion form of the
secondary specialties
Diagnostic results Contains the results from laboratory and diagnostic tests
Nursing admit Records data obtained from the interview and physical assessment
assessment sheet conducted by the nurses

Nursing care plan Contains the treatment plan, e.g., nursing diagnosis or a problem list,
initiation of standards of care, or protocols
• Graphic sheet List data related to vital signs and weight
• Flow sheet Contains all routine interventions that can be indicated via a check
mark or other simple code; allows for a quick comparison of
measurements
• Nurse’s progress Details of additional data without duplication information on the flow
notes sheet, e. g., client’s achievement of expected outcome, revision of
the plan of care
• Medication Contains all medication for routine and PRN (as needed) thugs: date,
administration tine, dose, route, site (for administration), form of medicines and
record(MAR) course of medication
• Client education Record both the nurses’ educational efforts directed toward the client
record family, or other care giver and the learner’s response
• Health care team Serves as the treatment and progress record for non-medical and non-
record nursing practitioners (e.g., respiratory, physical therapy, dietary)
when the physician’s progress notes are not used by those
practitioners
Critical pathway A multidisciplinary form for each day of anticipated hospitalization;
identifies the interventions and achievements of client outcomes;
in the progress notes, explains the initial practitioner’s
implementation and the variances from the norm
Discharge plan and A multidisciplinary form used before discharging from a health care
summary facility which contains a brief summary of care rendered and
discharge instructions (e.g., food-drug interactions or follow-up
appointments)
Advance directive or Federal law requires that health care providers discuss with the client
living will the use of advance directives, a living will or a durable power of
attorney. Most states recognize living will as a legal document. If
the client has advance directives, they are reviewed at the time of
admission and placed in the medical record

Tools for Documentation:


There are many tools used for client documentation and could be written or electronic in format and
they include:
Worksheets and kardexes:
Nurses use worksheets to organize the care they provide, and to manage their time and multiple
priorities. Kardexes are used to communicate current orders, upcoming tests or surgeries, special diets
or the use of aids for independent living specific to an individual client (College of Nurses of Ontario,
2002). If a paper format is used, entries may be erasable as long as the assessment, nursing
interventions carried out and the impact of these interventions on client outcomes are documented in
the permanent health record. When the Kardex is the only documentation of the client’s care plan, it is
kept as part of the permanent record
Client care plans:
Care plans are outlines of care for individual clients and make up part of the permanent health record.
Care plans are written in ink (unless electronic), up-to-date and clearly identify the needs and wishes of
the client
Flow sheets and checklists:
Flow sheets and checklists are used to document routine care and observations that are recorded on a
regular basis (e.g., activities of daily living, vital signs, intake and output). Flow sheets and checklists
are part of the permanent health record, and can be used as evidence in legal proceedings (College of
Nurses of Ontario, 2002).
Symbols may be used on flow sheets or checklists as long as it is clear who performed the assessment
or intervention and the meaning of each of the symbols is identified in agency policy
Care maps and clinical pathways:
Care maps and clinical pathways outline what care will be done and what outcomes are expected over a
specified time frame of a “usual” client within a case type or grouping. Nurses individualize care maps
and clinical pathways to meet clients’ specific needs (e.g., by making changes to items that are not
appropriate). If the status of clients varies from that outlined on the care map or clinical pathway at a
particular time period, the variance is documented, including the reasons and action plan to address it.

Monitoring strips:
Monitoring strips (e.g., fetal or thermal monitoring; blood pressure testing) provide important
assessment data and are included as part of the permanent health record
Nursing assessment sheet:
The nursing assessment sheet contains the patient’s biographical details (e.g. name and age), the reason
for admission, the nursing needs and problems identified for the care plan, medication, allergies and
medical history.
Nursing care plan:
The documents of the care plan will have space for:
• Patient/client needs and problems
• Nursing diagnoses are documented but these are not used as frequently as in North America
• Planning to set care priorities and goals Goal-setting should follow the SMART system, i.e. the goal
will be specific, measurable, achievable and realistic, and time-oriented
• The care/nursing interventions needed to achieve the goals
• An evaluation of progress and the review date. This might include evaluation notes, continuation
sheets, discharge plans and reassessment of patient
Vital signs:
The basic chart is used to record temperature, pulse, respiration and possibly blood pressure.
Sometimes the patient’s blood pressure is recorded on a separate chart. Basic charts may also have
space to record urinalysis, weight, bowel action and the 24—hour totals for fluid intake and output.
More complex charts, such as neurological observation charts, are used for recording vital signs plus
other specific observations, which include the Glasgow Coma Scale score for level of consciousness,
pupil size and reaction to light, and limb movement.
Fluid balance chart:
This is often called a ‘Fluid intake and output chart’ or sometimes just ‘Fluid chart’. It is used to record
all Fluid intake and Fluid output over a 24—hour period. The amounts may be totaled and the balance
calculated at 24.00 hours (midnight) or from 06.00 to 08.00 hours). Fluid intake includes oral,
nasogastric, via a Gastrostomy feeding tube, and infusions given intravenously, subcutaneously and
rectally. Fluid output from urine, vomit, and aspirate from a nasogastric tube, diarrhoea, fluid from a
stoma or wound drain are all recorded.

Medicine/Drug chart:
It is important for you to become familiar with the medicine! Drug-related documents used in your area
of practice. A basic medication record will contain the patient’s biographical information, weight,
history of allergies and previous adverse drug reactions. There will be a separate area on the chart for
different types of drug orders which includes:
• Drugs to be given once only at a specified time, such as a sedative before an invasive procedure
• Drugs to be given immediately as a single dose and only once, such as adrenalin (epinephrine) in an
emergency
• Drugs to be given when required, such as laxatives or analgesics (pain killers)
• Drugs given regularly, such as 7-day course of an antibiotic or a drug taken for longer periods (e.g.
a diuretic or a drug to prevent seizures). All drugs, except very few, are ordered using the British
Approved Name, and the order will include the dose, route, frequency (with times), start date and
sometimes a finish date. There is a space for nurse the signature who is giving the drug and, in
some cases, the witness
Informed consent:
Responsibility for making sure that the person or the parents of a child have all the information needed
for them to give informed written consent rests with the health practitioner (usually a doctor r nurse)
who is undertaking the procedure or operation. This information will include:
• Information about the procedure/operation
• The benefits and likely results
• The risks of the procedure/operation
• The other treatments that could be used instead
• That the patient/parent can consult another health practitioner
• That the patient/parent can change their mind
Young people can sign the consent form once they reach the age of 16 years and/or have the mental
capacity to understand fully all that is involved. If the young person cannot sign the form, the parent or
legal guardian may sign it If an adult lacks the mental capacity, either temporarily or permanently, to
give or deny consent, no person has the right to give approval for a course of action. However,
treatment may be given if it is considered to be in the person’s best interests, as long as an explicit
(clear) refusal to such action has not been made by the person in advance.
Doctors do most invasive procedures and operations, but nurses in the UK are extending their
practice to include many procedures that were previously done by doctors. You may work with nurses
who do procedures such as endoscopic examinations, so it is becoming more common for nurses to
obtain informed consent The patient or parent and the healthcare practitioner both sign the consent
form. When your patients are due to have any invasive procedure, always check their level of
understanding before it is scheduled to happen. If you are not sure about answering a question, ask the
healthcare practitioner who is doing the procedure to see the patient and explain again. It is essential
that the consent form is signed before the patient is given sedative or other premeditation drugs.
Incident/ Accident form / Incident Reports:
Agencies often have policies that require nurses to complete incident reports following unusual
occurrences, such as medication errors or harm to clients, staff or visitors. Regardless of whether
incident reports are used, nurses have a professional obligation to document the actual care provided to
an individual in the client’s health record. Incident reports are Administrative Risk Management tools
to track trends and patterns about groups of clients over time Incident reports are to be used for quality
assurance not punitive purposes. Incident reports completed in hospital based agencies are protected
from disclosure in legal proceedings under the section 51 of the Evidence Act (2001). Therefore, they
are retained separately from the health record and no reference to an incident report is made in the
health record to protect the incident report from subpoena.
Any non-routine incident or accident involving a patient/client, relative, visitor or member of
staff must be recorded by the nurse who witnesses (sees) the incident or finds the patient/client after the
incident happened. Incidents include falls, drug errors, a visitor fainting or a patient attacking a member
of staff in any way. An incident/accident form should be completed as soon as possible after the event.
Careful documentation of incidents is important for clinical governance and in case of a complaint or
legal action
The following points provide you with some guidance:
 Be concise, accurate and objective
 Record what you saw and describe the care you gave, who else was involved and do
describe the person’s condition
 Do not try to guess or explain what happened (e.g. you should record that side rails were not
in place, but you should not write that this was the reason the patient fell out of bed)
 Record the actions taken by other nurses and doctors at the time
 Do not blame individuals in the report
 Always record the frill facts.

Summary of categories of clinical record form:


Client information in a clinical record is documented in basic categories of forms, including
assessment or data base forms, clinical progress notes, and continuity of care forms:
1. Assessment and data base forms:
• Intake or admission records
• Nursing history and assessment
• Medical history and physical examination
• Test results;
 Labs
 X-ray
 ECG
 MRI
 CT scan reports
 Diagnostic test result data
2. Plan of care form or Care Plan Form:
Medical orders
Nursing care plan including nursing orders
Multidisciplinary care plan or discipline- specific plans documented on assessment/care plan or
progress notes
Teaching plans, which may be incorporated into a care plan
Kardex
Vital signs form
Intake and output chart
3. Progress notes forms:
• Clinical progress notes documented by all disciplines providing care
• Medication administration record (MAR)
• Outcomes reports;
Weekly narrative outcome summary note
Nursing plan outcome record
Criteria-based outcome record
4. Continuity of care forms:
• Teaching records
• Progress summary
• Transfer form
• Discharge summary

Principles of Documentation:
The following principles should be applied.
• The documentation is directed primarily to serving the interests of the client
 V The primary purpose of client I patient health records should be to facilitate the provision of
care
• Frequency of documentation of documentation is ultimately a professional judgment. Nurses should
ensure that all entries are:
 Chronological and timely
 Comply with any policy of the health care agency/organization
 Fulfill legal requirements
 Adhere to the principles listed in these standards
 The frequency of entries, made in a client’s / patient’s health record, is dependent on several
factors. These include, but are not restricted to:
o The physical / mental condition of the client/patient
o The method of documentation used by the health care facility/organization
o Any other obligations (legal or otherwise) that the health record must fulfill
 In circumstances where a client / patient is in unstable health, it is necessary to document more
frequently than in circumstances where the client/ patient may be in more stable health, such as
in long-term care
• The documentation records events chronologically and in a timely manner; Entries in client/ patient
health records should be in chronological sequence, with time, date, and signature and staff
designation
Entries must be made as close as possible, to the care or treatment provided
Waiting until the end of a shift to “write the report” should be avoided as such practices enhance the
likelihood of errors, omissions or “misremembering”
It is permissible to document at a later time if pertinent data is omitted or not included at the time an
event occurs. A late entry is preferable to no entry at all
To avoid confusion when documenting at a later time, include both the time and date that the entry
is made, and the time and date that the entry refers to- It is also permissible to add a brief
comment explaining why the documentation has occurred at the later time
If the record is to be amended in this way, it should always be undertaken by the nurse who
provided the care
Spaces should NOT be left in a client/patient’s record for documentation to be completed at a later
time

• The documentation is concise, legible, accurate, and contemporaneous; all entries should be brief,
complete, and unambiguous. Verbosity leads to difficulties in interpretation, and may delay access
to vital information. All entries must be made in ink, and any blank areas in a report should be ruled
out. All entries should include the date, and the time that the documentation occurs.
 A person making any documentation in a client/ patient record must be able to be identified;
therefore all entries in the health record, including signatures, should be legible. Nurses should
ensure that their name and designation is printed clearly with their signature, to aid
identification
 The record should not consist of subjective expressions of opinion on issues irrelevant to the
management of the client! patient
 Recording errors should be promptly corrected by drawing one line through the incorrect
information
 The time, date and signature of the person altering the record should then be entered. It is also
advisable to record the reason and brief description for alteration
 Under no circumstances should “white out” be used or an entry obliterated by scribbling over it
or tearing the entry out, as this greatly diminish the credibility of the record -
• The documentation is in an approved format:
 Health care agencies/organizations should ensure that they have written policies in regard to the
format. A tick () cannot be considered as an acceptable abbreviation, or as a substitute for time,
initials or a signature
 Health care agencies/organizations should ensure that they have written policies outlining the
requirements for registered nurses to countersign entries made by other health care workers e.g.
Students and unregulated health care workers. Such policies promote clear communication and
minimize the risk of incorrect interpretation of data
• The documentation uses approved abbreviations: Abbreviations in nursing documentation should be
kept to a minimum level
No abbreviation should be used unless it has a clear and unambiguous meaning
Health Care agencies/organizations should ensure that a list or book, with acceptable abbreviations
and terminology for use in client/patient health care records, is available

• The documentation contains only entries recorded by the individual practitioner who provided the
care:
 Nurses should not document on behalf of others
 All persons who provide care, make observations, should make an entry in the client’s I
patient’s health record
 The nurse, in accordance with the health care agency, should record verbal orders given to them
by another health care professional. This ensures continuity and safety of client/patient care
• The documentation demonstrates that the nurse has fulfilled their duty of care to the client
 All care, advice and any specific nursing management plans should be documented clearly in
the client’s / patient’s health record
 Duplication of information in health records should be avoided
 Refusal of treatment, advice or medication should be noted in the health record
• Auditing and monitoring of documentation: Planning and patient assessment rely heavily on
accuracy and quality in all documentation. Organizations are encouraged to regularly monitor and
audit documentation within their organization. Such procedures could be included within the annual
quality plan of departments and units:
Qualitative review - evaluating the quality of documentation and assessing adherence to clinical
practice standards, regulations, standards, interpretations and consistency within the
documentation. A qualitative review identifies strengths and weaknesses and provides
suggestions to correct future documentation discrepancies
Quantitative review — evaluating completeness, authenticity and timely entry of the
documentation. A simple assessment tool requiring a yes I no responses or checklist could be
used
• Documentation is a written plan for care which include:
Treatments and medications
Specifying frequency and dosage
Referrals and consultations
Patient or family education
Special instructions for follow-up

• Comprehensive, flexible and dynamic


• Reflect current standards
• Medical record should be complete and legible
• Each Patient I Client encounter should include:
 Date
 Reason for the encounter
 Appropriate history and physical examination
 Review of labs, x-ray and other ancillary
 Assessment
 Plan for care including discharge plan
Documentation may be accessible including past and present diagnoses to the treating and br consulting
physician and health care provider
Reasons and results of:
 x-rays
 lab test
 Other ancillary services
 Relevant health risk factors
Documentation of patient’s progress includes:
 Intervention
 Response to treatment or intervention
 Change in treatment
 Change in diagnosis
 Patient non-compliance
Documentation should support the intensity of the patient’s evaluation and/or treatment including
thought processes and complexity of medical decision making.

Standards of Practice:
A standard is a desired and achievable level of performance against which actual performance can be
compared. Each of the six Professional Standards incorporates one of the characteristics of the
profession and provides direction to nurses about documentation.
Responsibility and Accountability: Maintains standards of nursing practice and professional conduct
determines the practice setting. Examples:
Document all relevant data. Ensure that each entry clearly identifies the nurse
Be familiar with and use the documentation method used in the agency
Advocate for agency policies and procedures that are clear and consistent with CRNBC
documentation standards
Specialized Body of Knowledge: Bases practice on the best evidence and other sciences and
humanities. Example:
 Understand the purpose of and reasons for accurate and effective documentation
Competent Application of Knowledge: Makes decisions about actual or potential health problems and
strengths, plans and performs interventions, and evaluates outcomes.
Examples:
 Document client assessments, interventions and the impact of interventions on client outcomes
according to agency policies and the CRNBC Standards of Practice. Individualize care plans to
meet the needs and wishes of individual clients
• Code of Ethics: Adheres to the ethical standards of the nursing profession. Examples:
Be familiar with agency policies related to confidential information
Safeguard the security of printed, electronically displayed or stored information
Dispose of confidential information in a manner that preserves confidentiality
Act as an advocate to protect and promote clients’ rights to confidentiality and access to
information
Provision of Service in the Public Interest: Provides nursing services and collaborates with other
members of the health care team in providing health care services. Examples:
 Use documentation to share knowledge about clients with other nurses and health care
professionals.
 Regularly update Kardex information and ensure that relevant client care information is
captured in the permanent health record.
 Keep the care plan clear, current and useful.

Self-Regulation: Assume primary responsibility for maintaining competence and fitness to practice.
Example:
 Keep current with changes in the documentation method used
 Practice Standard: Documentation
 The Practice Standard Documentation sets-out requirements related to documentation and
nurses’ practice
 It also provides direction on how to apply the principles in the Standard to practice
Other standards of documentation
Agency policies and procedures: Most health care agencies have documentation policies. These
policies provide direction for nurses to document the nursing care provided and the process of
clinical decision-making in an accurate and efficient manner.
Agency policies includes:
 Description of the method of documentation
 Expectations for the frequency of documentation
 Processes for “late entry” recording
 Listing of acceptable abbreviations or the name of a reference text in which acceptable
abbreviations are found
 Acceptance and recording of verbal and telephone orders
 Storage, transmittal and retention of client information
Agency policies guide nurses in managing each of these specific situations In situations where
policy changes are necessary, nurses advocate for the appropriate changes
Legal Principles: Legal standards for documentation have evolved over a time and continue to evolve.
Many are based on Canadian common law court decisions
Nurses’ notes are recognized as documentary evidence:
Case: Ares vs. Venner, 1970
Prior to 1970, nurses’ notes were not considered legal evidence admissible in court unless the nurse
was called to testify to the truth of the contents. In 1970, a new law was made in the Ares vs.
Venner case when, for the first time, nurses’ notes were recognized as admissible evidence. Nurses’
notes were viewed as a record of the nursing care provided to the client. This case set out the
conditions in which nurses’ notes are now admissible (Richard, 1995):
Nurses’ notes must be made contemporaneously
Nurses’ notes must be made by someone having personal knowledge of the matter then being
recorded
Nurses’ notes must be made by someone under a duty of care to make the entry
Charting by exception can provide admissible evidence:
Cases: Kolesar vs. Jeffries, 1974; Ferguson vs. Hamilton, 1983; Wendon vs. Trikha, 1993. The
health record is important both for what is recorded and for what is not recorded. In the case of
Kolesar vs. Jeffries (1974), the nurses’ notes were introduced as evidence and the absence of
entries permitted the inference that “nothing was charted because nothing was done.” However,
in a subsequent case, Ferguson vs. Hamilton (1983), the court rejected the submission that the
absence of any nurse’s entry is an indication of failure in care on the part of the nurse(s). In this
case, the court concluded that the fact that there was nothing in the nurses’ notes during a period
of time did not necessarily mean nothing was done, provided there was evidence to the contrary
and the usual practice was not to chart (Richard, 1995)
In the case of Wendon vs. Trikha (1993), the court concluded that omissions in documentation will
be interpreted against a nurse unless other credible evidence of nursing care demonstrates that
care was given. It means that if charting by exception is an agency policy, and if evidence can
be given that care was provided and noted according to this method, then this evidence will be
admissible and will provide proof of what was done (Richard, 1995). To meet legal
documentation standards, a system of charting by exception must include such supports such as
agency documentation policies, assessment norms, standards of care, individualized care plans
and flow sheets

Methods of Documentation:
Documentation must reelect the complexity of care and must embody accuracy, completeness, and
evidence of professional practice. The clinical standards (structure, outcome, process, and evaluation)
are used to develop a system that complies with legal, accreditation, and professional practice
requirements of documentation. The documentation method selected within an agency or practice
setting needs to reflect client care needs and the context of practice. Some agencies may combine
elements of different documentation methods and formats. If an agency decides to change its method or
format of documentation and expectations, it is important that this be done within a context of
appropriate planning and includes the involvement and education of nurses. Regardless of the method
used, nurses are responsible and accountable for documenting client assessments, interventions carried
out, and the impact of the interventions on client outcomes. Clients who are very ill, considered high
risk, or have complex health problems generally require more comprehensive, in-depth and frequent
documentation. Most methods of documentation fall into one of two categories:
Documentation by inclusion (Coleman, 1997): Documentation by inclusion is done on an ongoing,
regular basis and makes note of all assessment findings, nursing interventions and client outcomes
Documentation by exception: on the other hand, makes note of negative findings and is completed
when assessment findings, nursing interventions or client outcomes vary from the established
assessment norms or standards of care existing within a particular agency
Different methods of documentation are:
• Narrative Documentation or Narrative charting: Narrative charting is a method in which
nursing interventions and the impact of these interventions on client outcomes are recorded in
chronological order covering a specific time frame. Data is recorded in the progress notes, often
without an organizing framework. Narrative charting may stand alone or it may be
complemented by other tools, such as flow sheets and checklists It is the traditional method of
nursing documentation, takes the form of a story written in paragraph and describing the client’s
status, interventions and treatments, and client’s response to treatments. Before the advent of the
flow sheets, this was the only method for documenting care. Narrative documentation is easy to
use in emergency situations, wherein a simple, chronological order is needed. Narrative charting
is now replaced by other formats because:
 The flow of care is disorganized. It is difficult to show- the relationship between data and
critical thinking skills. Each nurse writes in a unique style, making continuity of care
difficult to identify.
 It fails to reflect the nursing process. The focus is on tasks rather than on assessment data or
progress toward achievement of outcomes
 It is time consuming. Because the paragraphs are free flowing, it takes more time both to
accurately record information and to read information recorded other
 The information is difficult to retrieve, and because the same problems may be addressed
from shift to shift, it is difficult to track the client’s progress
Source-oriented charting: It is described as a narrative recording by each member (source) of the health
care team on separate records, because each discipline uses a separate record, care is often
fragmented, and communication between disciplines is time-consuming. Source-oriented charting
has similar advantages and disadvantages to narrative charting, because both methods take an
unstructured approach to documenting in the progress notes
Problem oriented medical records (PMOR) or Problem-oriented charting:
It focuses on the client’s problem and employs a structured, logical format called SOAP charting /
SOAPIE (R) Charting. SOAP/SOAPIER charting are a problem-oriented approach to
documentation whereby the nurse identifies and lists client problems; documentation then follows
according to the identified problems. Documentation is generally organized according to the
following headings:
 S Subjective data (e.g., how does the client feel?)
 O Objective data (e.g., results of the physical exam, relevant vital signs)
 A Assessment (e.g., what is the client’s status?)
 P Plan (e.g., does the plan stay the same? is a change needed?)
 I Intervention (e.g., what occurred? what did the nurse do?)
 E Evaluation (e.g., what is the client outcome following the intervention?)
 R Revision (e.g., what changes are needed to the care plan?)

There are four critical components of problem-oriented medical record (POMR)/problem oriented
record (POMR) as under:
 Database
 Problem list
 Nursing care plan
 Progress note
SOAP (IE) stands for:
 Subjective
 Objective
 Assessment
 Plan
 intervention
 Evaluation
• PIE charting: After SOAP charting gained popularity, the problem, intervention, evaluation (PIE)
charting system evolved to streamline documentation. The key components of this system are
assessment flow sheets, nurse’s progress notes, and an integrated plan of Care. This system
eliminates the traditional care plan by incorporating an ongoing plan of care (problem, intervention,
evaluation) into the daily documentation.
1. PIE stands for:
o Problem, Intervention, Evaluation
2. DAR stands for:
o Data, Action, Response
• Focus Charting: It is a documentation method that uses a column format to chart data, action, and
response (DAR). The column format of focus charting is used within the progress notes to
distinguish the entry form and other recordings in the narrative notes .With this method of
documentation, the nurse identifies a “focus” based on client concerns or behaviors determined
during the assessment. For example, a focus could reflect:
 A current client concern or behavior, such as decreased urinary output.
 A change in a client’s condition or behavior, such as disorientation to time, place and person
 A significant event in the client’s treatment, such as return from surgery

In focus charting, the assessment of client status, the interventions carried out and the impact of the
interventions on client outcomes are organized under the headings of data, action and response.
 Data: Subjective and/or objective information that supports the stated focus or describes the
client status at the time of a significant event or intervention
 Action: Completed or planned nursing interventions based on the nurse’s assessment of the
client’s status
 Response: Description of the impact of the interventions on client outcomes
• Charting by exception (CBE): It is a documentation method that requires the nurse to document
only deviations from pre-established norms. This system has three key components:
 Flow sheets and checklists are frequently used as an adjunct to document routine and ongoing
assessments and observations such as personal care, vital signs, intake and output, etc.
Information recorded on flow sheets or checklists does not need to be repeated in the progress
notes
 Reference documentation: related to the standards of nursing practice
 Besides accessibility: related to the documentation forms
 Reduces repetition and time
 Shorthand for normal findings and routine care
 Based on clearly defined standards and criteria
 Predefined findings
 Predetermined interventions
• Critical pathway: A critical pathway (or critical path) is a comprehensive, standard plan of care for
specific case situation. The pathway is monitored to ensure that interventions are performed on time
and that client outcomes are achieved on time. Variations, sometimes referred to as variances, are
goals not met or interventions not performed according to the established time frame. The nurse
documents on the back of the critical pathway the unexpected event (e.g., medications not given
because client in physical therapy), actions taken in response to the event, and appropriate discharge
planning Critical pathways allows the efficient use of time and increase the quality of care by
having the expected outcomes identified on the plait When clients have more than two diagnoses or
variations, however, documentation becomes complicated because of limited space. This situation
requires additional documentation forms to complement the pathway, such as intervention flow
sheet

• Computerized documentation or use of technology: In response to large demand for clinical,


administrative, and regulatory information in today’s health care system, nurse leaders are working
to develop computerized records. The resultant of Nursing Information Systems (NIS) will
complement exciting hospital information system (FIIS) and will collect, store, process, retrieve,
display, and communicate timely information. Health care facilities work in collaboration with
producers of computer software to design medical record documents that complements exciting
documentation systems. Computerized documentation enhances the systematic approach to client
care with standardized protocols, teaching documents, data management, and communication. It
gives to practical advantages to staff nurses which are as follows:
Advantages are:
 Decreased documentation time
 Increased legibility and accuracy
 Clear, decisive, and concise key words
 Statistical analysis of data
 Enhanced implementation of the nursing process
 Enhanced decision making
 Multidisciplinary networking
Disadvantages are:
 High cost of installation
 Limit numbers of terminals at nursing stations
 Slow processing speed at peak usage times
 Downtime (time of routine servicing or unexpected failure)
 Legal issues as Legal risk of breaches of confidentiality
 Charting errors so nothing is deleted
• Use of Technology: Technology may be used to support client documentation in a number of ways.
If technology is used, the principles underlying documentation, access, storage, retrieval and
transmittal of information remain the same as for a traditional, paper-based system. These new
ways of recording, delivering and receiving client information, however, pose significant challenges
for nurses, particularly with respect to confidentiality and security of client information. It is
important that nurses be supported by agencies in resolving these issues through clear policies and
guidelines and ongoing education
 Electronic documentation: A client’s electronic health record is a collection of the personal
health information of a single individual, entered or accepted by health care providers, and
stored electronically, under strict security. As with traditional or paper-based systems,
documentation in electronic health records must be comprehensive, accurate, timely, and clearly
identify who provided what care (College of Nurses of Ontario, 2002)
o Entries are made by the care provider providing the care and not by other staff
o Entries made and stored in an electronic health record are considered a permanent part
of the record and may not be deleted
o If corrections are required to the entry after the entry has been stored, agency policies
provide direction as to how this should occur
Most agencies are using electronic documentation and policies to support its use, and include policies
for:
 Correcting documentation errors or making “late entries”
 Preventing the deletion of information
 Identifying changes and updates to the record
 Protecting the confidentiality of client information
 Maintaining the security of the system (passwords, virus protection, encryption, firewalls)
 Tracking unauthorized access to client information
 Processes for documenting in agencies using a mix of electronic and paper methods
 Backing-up client information
 Means of documentation in the event of a system failure
Guidelines for nurses using electronic health records which are as follows:
 Never reveal or allow anyone else access to your personal identification number or password as
these are, in fact, electronic signatures
 Inform your immediate supervisor if there is suspicion that an assigned personal identification
code is being used by someone else
 Change passwords at frequent arid irregular intervals (as per agency policy)
 Choose passwords that are not easily detectable
 Log off when not using the system or when leaving the terminal
 Maintain confidentiality of all information, including all print copies of information
 Shred any discarded print information containing client identification
 Locate printers in secured areas away from public access
 Retrieve printed information immediately
 Protect client information displayed on monitors (e.g., use of screen saver, location of monitor,
use of privacy screens)
 Use only systems with secured access to record client information
 Only access client information which is required to provide nursing care for that client;
accessing client information for purposes other than providing nursing care is a breach of
confidentiality
• Fax transmission: Facsimile (fax) transmission is a convenient and efficient method for
communicating information between health care providers. Protection of client confidentiality is the
most significant risk in fax transmission and special precautions are required when using this form
of technology
Guidelines for protecting client confidentiality when using fax technology to transmit client
information are as follows:
 Locate fax machines in secured areas away from public access
 Check that the fax numbers and/or fax “distribution lists” stored in the machine of the sender
are correct prior to dialing
 Carefully check activity reports to confirm successful transmission
 Include cover sheet warnings indicating the information being transmitted is confidential; also
request
 Verification that, in the event of a misdirected fax, it will be confidentially and immediately
destroyed without being read
 Make a reasonable effort to ensure that the fax will be retrieved immediately by the intended
recipient, or will be stored in a secure area until collected
 Shred any discarded faxed information containing client identification
 Advocate for secure and confidential fax transmittal systems and protocols
Client information received or sent by fax is a form of client documentation and is stored electronically
or printed in hard copy and placed in the client’s health record. As the fax is an exact copy of original
documentation, additional notations may be made on the faxed copy as long as these meet the agency
standards for documentation and are appropriately dated and signed. Faxes are part of the client’s
permanent record and, if relevant, can be subject to disclosure in legal proceeding

• Electronic Mail: The use of e-mail by health care organizations and health care professionals is
becoming more widespread as a result of its speed, reliability, convenience and low cost.
Unfortunately the factors that make the use of e-mail so advantageous also pose significant
confidentiality, security and legal risks. E-mail can be likened to sending a postcard. It is not sealed,
and may be read by anyone. Because the security and confidentiality of e-mail cannot be
guaranteed, it is not recommended as a method for transmission of health information. Messages
can easily be misdirected to or intercepted by an unintended recipient. The information can then be
read, forwarded and/or printed. Although messages on a local computer can be deleted, they are
never deleted from the central server routing the message and can, in fact, be retrieved. Having
considered these risks and alternative ways to transmit health information, e-mail may be the
preferred option to meet client needs in some cases. Guidelines for protecting client confidentiality
when using e-mail to transmit client information are as follows:
 Obtain written consent from the client when transferring health information by e mail
 Check that the e-mail address of the intended recipient(s) is correct prior to sending
 Transmit e-mail using special security software (e.g., encryption, user verification or secure
point-to-point connections)
 Ensure transmission and receipt of e-mail is to a unique e-mail address
 Never reveal or allow anyone else access to your password for e-mail
 Include a confidentiality waiting indicating that the information being sent is confidential and
that the message is only to be read by the intended recipient and must not be copied or
forwarded to anyone else
 Never forward an e-mail received about a client without the client’s written consent
 Maintain confidentiality of all information, including that reproduced in hard copy
 Locate printers in secured areas away from public access
 Retrieve printed information immediately
 Advocate for secure and confidential e-mail systems and protocols

From the nurse’s perspective, it is important to realize that e-mail messages are a form of client
documentation and are stored electronically or printed in hard copy and placed in the client’s health
record. E-mails are part of the client’s permanent record and, if relevant, can be subject to disclosure in
legal proceedings. E-mail messages are written with this in mind. Similar to physicians’ orders received
by fax, if physicians’ orders are received by e-mail, nurses use whatever means necessary to confirm
the authenticity of the orders.
• Tele nursing: Giving telephone advice is not a new role for nurses. What is new is the growing
number of people who want access to telephone “help lines” to assist their decision-making about
how and when to use health care services. Agencies such as health units, hospitals and clinics
increasingly use telephone advice as an efficient, responsive and cost-effective way to help people
care for themselves or access health care services. Nurses who provide telephone care are required
to document the telephone interaction. Documentation may occur in a written form (e.g., log book
or client record form) or via computer. Standardized protocols that guide the information obtained
from the caller and the advice given are useful in both providing and documenting telephone
nursing care. When such protocols exist, little additional documentation may be required. Minimum
documentation includes the following:
 Date and time of the incoming call (including voice mail messages)
 Date and time of returning the call
 Name, telephone number and age of the caller, if relevant (when anonymity is important, this
information may be excluded)
 Reason for the call, assessment of the client’s needs, signs and symptoms described, specific
protocol or decision tree used to manage the call (where applicable), advice or information
given, any referrals made, agreement on next steps for the client and the required follow-up
 Tele-nursing is subject to the same principles of client confidentiality as all other types of
nursing care

Other Forms of Communication


 Team meetings
 Multidisciplinary team members share information
 Members identify problems and solutions
 Consultation
 One professional gives advice to another Patient Report
o Nurse to nurse report when providers change
o Nurse to nurse report at change of shift.
o Nurse to provider report for change of condition or for instruction
o Diagnostic reports from diagnostic departments (x-ray, lab, etc.)
 Long Term Care Documentation
o Documentation often done on flow sheets and less frequently
o Caregiver qualifications
o Assessments
o Individualized care plans
o Nursing care must be justified by the documentation
Role of communication in Nursing Theory and its Impact on Documentation:
Nursing theory communicates a particular view of what nursing practice is. A common thread of
communication is evident in each theory or view of the practice of nursing. As nursing theories
continue to evolve, it is unlikely that any nursing theory would exclude this vital component of
interaction among nurses and patients. The work of nursing theorists guides the daily practice of many
nurses by giving them an organizing framework for their practice. If a hospital uses a particular nursing
theory, the design of documentation forms reflects that theory. For example, admission assessments
based on the theory by Sister Callista Roy would include specific reference to the stimuli that have
identified for particular patients and nursing diagnoses that describe the person’s level of adaptation. As
nursing in that hospital discuss patient care, they would communicate in terms consistent with Roy’s
view of nursing. The result is communication with a common set of ideals and an established
vocabulary.

Nursing Care Documentation:


• “Physician extenders” including nurses, nurse practitioners, and physician assistants
• Sources of documentation requirements
 JCAHO (Joint Commission on Accreditation of Health Care Organization)
 Medicare Conditions of Participation
 State regulations
 Facility-specific nursing policies
• Documentation should be
 Consistent
 Complete
 Concise
 Accurate
Why it matters:
• Defensive vs. “offensive”
• Clinical indicators—the clues for coders as to what is really going on with the patient
• Better nursing documentation means
 Accurately reflecting the severity and complexity of patients treated
 Complete reporting services provided to patients
 Consistent capture of nursing activities
JCAHO Requirements (Joint Commission on Accreditation of Health Care Organization)
• Assessment of needs
 Physical
 Psychosocial
 Environmental
 Self care
 Client education
 Discharge plan

Evaluation of outcomes
 Response to treatment
 Teaching
 Preventive care
 Client status
 Degree of progress
 Family involvement
Guidelines for Documentation
• Factual
• Accurate
• Complete
• Current
• Organized
Record Keeping Forms
• Nursing history (FIX)
• Graphic or flow sheet
• Medication administration record
• Nursing KARDEX
• Acuity recording systems
• Standardized care plans
• Discharge summary

The aims of documentation process are:


• To develop a nationally unified and standardized nursing documentation
• To integrate the nursing documentation into the multi-professional patient record
• To use the standardized nursing data to manage and assess the quality of the nursing process
The nursing minimum data set in Finland:
In Finland the Nursing Minimum Data Set includes information on the nursing diagnosis, interventions,
outcomes, intensity and discharge summary.
• The data are gathered using a structured documentation during the nursing process
• The information is used in present and future care
Implementation of structured nursing documentation:
The Council of State of Finland has made a national, coherent (unified) system of processing, storing,
communicating and assessing of electronic patient records. The electronic nursing documentation
module includes nursing diagnosis, interventions and outcome notes. The model is used in nursing care
planning and for making daily notes. The components of The Finnish Classification of Nursing
Diagnosis (FiCND) and The Finnish Classification of Nursing
Interventions (FiCNI) are:
• Elimination
• Role relationship
• Safety
• Self care
• Psychological regulation
• Sensory
• Skin integrity
• Continued treatment
• Activity
• Coping
• Fluid volume
• Health behaviors
• Health services
• Medication
• Nutrition
• Physical regulation
• Respiration

Benefits of structured nursing documentation:


• Enables a multi-professional search for information > use i decision-making
• Enables the making of summaries
• Gives information about the processes of the nursing process (also in relation to the medical
diagnose)
• Provides statistics and reports for the management, planning and managing of activities and
effectiveness of nursing, and quality assessment
Results so far
• Achieved advantages of the structured documentation: real-time information, continuity and
security of nursing care.
• Nursing documentation practices have become more uniform and patient-centered
• Overlapping in documentation have decreased and multi-professional cooperation has increased
• The quality of the nursing documentation content has improved
• Standardized nursing documentation speeds up the recording and guides to document the contents
of nursing
Groups of Clients: When providing service to groups of clients (e.g., therapy groups, public health
programs), service records (or an equivalent) are used to document the service provided and overall
observations pertaining to the group. Similar to documentation for individuals, documentation for
groups reflects the needs assessment, plans, actions taken, and evaluation of the group outcomes.
Documentation of services provided to a group of clients describes:
• The purpose and goal of the group
• The criteria for participation
• Intervention activities and group processes;
• An evaluation of group outcomes
Pertinent information about individual clients within the group is documented on individual client
health records, not on the group service record. When charting on an individual client health record,
names of other group members are not identified.

British Columbia Health Care Risk Management Society (2002) recommends the following:
• Ensure that the facts of the incident are recorded separately from opinions about the cause of the
incident and from any quality assurance follow-up information
• Some organizations have a two-part incident report with follow-up and recommendations separate
from the rest of the report
• Never promise a patient/family a copy of an incident report or of any report arising out of quality
assurance investigation - section 51 of the Evidence Act prohibits this;
 Directives for Documentation: Requirements for documentation and the sharing, retention and
disposal of this information are drawn from several sources: statutory regulations; Standards of
Practice; agency policies and procedures; and legal principles
 Statutory Regulations: There are no laws in BC stating specifically how and what nurses must
document. Agencies generally develop documentation policies which reflect provincial and
federal government statutes and/or other relevant documents
The following statutes and documents guide policy in most B.C. agencies:
• British Columbia Coroners Act
• Health Professions Act
• Child, Family and Community Service Act
• Hospital Act
• Controlled Drug and Substances Act (Federal)
• Health Care (Consent) and Facilities Act
• Electronic Transactions Act
• Limitation Act
• Evidence Act
• Medical Practitioners Act
• Freedom of Information and Protection of Privacy Act
• Mental Health Act
• Health Act
Common Questions about Documentation:
1. What information is included in the progress notes?
Progress notes (nurses’ notes) are used to communicate nursing assessments, interventions carried
out, and the impact of these interventions on client outcomes. In addition, progress notes are
intended to include:
• Client assessments prior to and following administration of PRN medications
• Information reported to a physician or other health care provider and, when appropriate, that
provider’s response
• All client teaching
• All discharge planning, including instructions given to the client and family and planned
community follow-up
• All pertinent data collected in the course of providing care, including data collected through
technology such as monitoring devices (e.g., strips produced during cardiac or fetal monitoring)
• Advocacy undertaken by the nurse on behalf of the client
2. What is considered “timely” documentation?
The timeliness of documentation will be dependent upon the client. When client acuity,
complexity and variability are high, documentation will be more frequent than when clients are
less acute, less complex and/or less variable. Graphically, this is shown as follows:
Low Medium High
Acuity

Complexity

Variability

Frequency of
Documentation

3. Who owns the health record?


The self-employed nurse or the agency in which the client’s health record is compiled is the legal
owner of the record as a piece of physical or electronic property. The information in the record,
however, belongs to the client. Clients have a right of access to their records and to protect their
privacy with respect to the access, storage, retrieval and transmittal of the records. The ri of clients
and obligations of public agencies are outlined in the Freedom of Information and Privacy Act and
are often summarized in agency policies.
4. How do the Freedom of Information and Protection of Privacy Act (FOIPPA) affect
documentation?
The FOIPPA provides the legislative framework for information and privacy rights. This act applies
to all public bodies, including hospitals, health authority boards, CRINBC and similar
organizations. The legislation gives the public a right of access to records held by one of these
public bodies. Individuals have a right of access to personal information about themselves and a
right to request correction of such information. The act also prevents the unauthorized collection,
use or disclosure of personal information by a public body
5. Is the information in the client’s health record confidential?
Yes, Information in the health record is considered confidential. Client consent for disclosure of
this information to agency staff for purposes related to care and treatment is implied upon
admission, unless there is a specific exception established by law or agency policy. Client
consent is required if the contents of the health record are to be used for research or if any client
information is to be transmitted outside the agency.
Nursing documentation must be produced according to agency policy when:
• Clients request access to their personal records
• CRNBC, under the Health Professions Act and Regulation needs to inspect or
investigate records
• A subpoena is provided (e.g., negligence suit)
• A statutory mandate requires the release of the information (e.g., reporting
communicable diseases or child abuse)

6. Do clients have access to their health record?


Yes. The CRNBC Standards of Practice require that nurses provide clients, in appropriate
circumstances, with access to their health records or assist them to obtain access to these records.
These standards are consistent with the Freedom of Information and Protection of Privacy Act
whereby clients can submit written requests for access to their records or for information that might
otherwise not normally be provided. Refer to agency policy as to the process to follow when clients
request access to their health records
7. What happens to third party information when information in a health record is to be released?
Nurses may obtain relevant information about a client or an incident from another person, such as
the client’s family member or friend. Nurses may also learn information about a third party that is
relevant to the client. When a client’s record has another person’s name on it or contains
information about another person — especially if the information was given in confidence - the
record may need to be “severed” before it is released. This means that some portions of the record
are removed and not released to the client requesting the record. For example, if the client’s record
included the name of a friend of the client or another client, the section of the record that includes
this information would need to be removed before releasing the record to the client
8. How is client information contained in communication books and shift reports communicated?
Communication books and shift reports are used to alert the health care team to critical information.
These tools are used to direct others to the health record where the pertinent information is recorded
in detail. Relevant health information communicated by these tools is documented in the health
record (College of Nurses of Ontario, 2002)
9. Should I document incidents where calls are made because of a concern about a specific client, but
are not returned?
It is important to document only facts on client health records. In cases where calls are made
because of a concern about a specific client, a notation of these calls is made in the progress
(nurses’) notes. A notation is made after each call, regardless of whether the call was returned. If a
call is returned, that is noted

10. Under which circumstances are verbal orders appropriate?


• Telephone orders
Orders accepted over the telephone are generally made without the physician’s direct
assessment of the client’s condition. Decisions are based solely on the nurse’s assessment of the
client. Any miscommunication or lack of communication could lead to negative implications for
the client. Errors in recording telephone orders can also occur and there is always the question
of who made the error, the physician in ordering, or the nurse in recording. Despite these
concerns, there are times when telephone orders may be the best option for the client .In these
cases, the nurse makes himself aware of the agency’s policy with regard to accepting and
documenting telephone orders. Orders left on answering machines are not acceptable.
• Documenting Telephone Orders
 Write down the time and date on the physician’s order sheet.
 Write down the order given by the physician.
 Read the order back to the physician to ensure it is accurately recorded.
 Record the physician’s name on the physician’s order sheet, state “telephone order,”
 Print your name, sign the entry and identity your status (e.g., RN).
• On-site verbal orders
On-site verbal orders also have the potential for error and are avoided unless in an emergency
situation, such as a cardiac arrest. Nurses need to be aware of the agency’s policy with regard to
accepting and documenting on-site verbal orders. Of nursing staff; only registered nurses take
verbal orders (and telephone orders) pertaining to medications.
• Orders taken verbally and recorded by pharmacists
In B.C., pharmacists can accept and record verbal orders from physicians to dispense medications.
In these circumstances, nurses can carry out the orders from the label on the dispensed medication.
• Should chart pages or entries be recopied?
Under no circumstances are chart pages or entries recopied. Errors are corrected according to
agency policy. If information is difficult to read, then add information in a “note to chart” or “note
to file.”

11. How are “after the fact” notes developed by nurses for potential use in the future handling?
There are occasions when nurses write notes “after the fact” (e.g., one day later, one week later),
most often to provide clarification following an “incident” or an unexpected client outcome Nurses
usually write these notes while the event is current in the nurse’s memory, in case of an
investigation or lawsuit at a later date. It is recommended that nurses do not keep these notes at
home but provide them to a supervisor or risk manager within the agency for safe keeping
12. How long do health records need to be kept?
Self-employed nurses and agencies should have policies on the retention of health records and
client documentation. Current legislation needs to be considered in the development of these
policies. Legislation differs, depending upon the setting. In all settings, records that contain
references to blood or blood products must be maintained in perpetuity (MOH communication,
1996/1997). In other words, these records must be kept forever.
In acute care hospitals, documents contained in the health record may be considered primary,
secondary or transitory. Records are kept for the following time periods (from date of discharge):
 Primary documents (e.g., physicians’ orders, nursing admission assessment, consultations,
discharge summary, and notice of death) - 10 years
 Secondary documents (e.g., most diagnostic reports, medication records, flow sheets and
nurses’ notes) —6 years
 Transitory documents (e.g., diet report, graphic chart) - 1 year depending upon agency policy,
records of minors may be required to be kept longer than the time periods listed above
In community care, public health and mental health settings, client records of adults are
generally kept for 10 years and minors for 25 years from the date of service.
Some exceptions apply to the timeframes listed above, requiring certain practice settings to have
longer retention periods (e.g., forensic mental health). Nurses need to be aware of agency policy
and legislation impacting these retention periods

13. What records are self-employed nurses required to keep?


Self-employed nurses must have a documentation system. What is recorded will depend on the type
of service offered. Forms can be simple and still address nursing assessment, plans, interventions
and client outcomes. The CRNBC Practice Standard Self-Employed Nurse provides direction on
documentation requirements for self-employed nurses and is available from the CRNBC website.
The following standards are intended to assist individual professional judgment and the
development of local policies. The standards are not intended to be all-inclusive and should be
treated as a guide only.
Legal and Professional Issues:
Legal Issues: Any document which records any aspect of the care of a client/patient can potentially be
examined during the investigation of a complaint by authorities with relevant jurisdiction. In these
circumstances, the documentation will be closely and carefully scrutinized and the standard of care
given will be expected to be reflected by the standard of documentation. An absence of documentation
would ordinarily be interpreted as inferring that nothing was done in a particular circumstance.
As legal proceedings may occur after significant periods of time have elapsed since the care was
provided, Courts tend to give greater credibility to the accuracy of written, timely notes over verbal
evidence reliant solely on memory. Contrary to the hearsay rule of evidence, (which prevents evidence
from being admitted into court proceedings unless a witness can give first hand evidence of what
occurred), health records may be admitted without the person/s who actually wrote the record, being
present to give evidence For this reason, and because the documentation will thereby better fulfill its
primary purpose of serving the interests of the client/patient, nurses need to ensure that their
documentation is accurate, comprehensive, and legible.
• Ethical Issues: Accurate and comprehensive documentation honors the ethical concepts on which
best practice is based and demonstrates the basis for professional and clinical decisions. Inherent in
a nurse’s responsibility to ensure objective, contemporaneous, comprehensive, relevant and legible
documentation of a client’s/patient’s care, is the need to ensure that the ethical values of
professional practice are understood and fulfilled. Such values include the need to protect
confidentiality, to ensure informed consent, and respect the values and rights of individual
clients/patients. These values are detailed in the Australian Nursing Council’s Code of Ethics for
Nurses in Australia (2002).

• Confidentiality: The protection of personal information from privacy infringement is an issue of


major concern for the health sector and to informed health consumers. Nurses have an ethical and a
legal duty to maintain confidentiality so that personal information of clients /patients does not
become known by persons other than those who are directly involved in their care Information
contained in patient records should be held in confidence and viewed only by those who have a
legitimate right access to these records. Other health care professionals may require future access to
these records to ensure continuity of care, for example the Aged Care Assessment Team or
Community Nursing groups Clients/patients must be secure in the knowledge that the information
that they share it treated with respect for their privacy and is kept secure and confidential. There are
some statutory and other obligations, which override a nurse’s duty to maintain confidentiality.
These include, but are not restricted to:
Statutory Obligations
• Notification of Births Act 1966
• Coroner’s Act 1957
• Road Safety (Alcohol and Drugs) Act 1970
• Health Complaints Act 1995
• PrivacyAct200l
• Firearms Act 1997
• Public Health Act 1997
• Children, Young Persons and Their Families Act 1997
Other Obligations
• Subpoena
• Warrants
Nurses are advised that if they are unclear of their obligations in regard to the maintenance of
confidentiality, they should seek professional legal advice or guidance from the Nursing Board in cases
of doubt.

• Electronic Documentation: The application of electronic in technology for documentation should


not be allowed to breach the important principle of confidentiality. Nurses must satisfy themselves
about the security of the system used and should ascertain the accessibility of the records to which
they contribute important personal and confidential information. Organizations are encouraged to
have policies and procedures in place for staff that directly relate to the use and maintenance of, and
access to any electronic information system. Examples of such mechanisms include personal
identification codes, authentication encryption, and segregation of different information classes.
Legal advice should be obtained prior to the establishment of such a system. Issues that should be
considered with the use of electronic documentation include, but are not restricted to:
 Who -will have access to the records
 How corrections will be made
 Who will make corrections in records
 Under what circumstances will corrections be made
 What mechanism/s prevent erasure of all or part of the record
 How entries will be identified
Appropriate access control mechanisms should be used with electronic records to both validate entries
and prevent unauthorized access. When using an electronic information system, it is important to
ensure a duplicate of all information stored is maintained and that the responsibility for this is clearly
delegated to an appropriate person. Adapted from Standards Australia, Personal Privacy Protection in
Health Care Info Systems (1995)
• Storage and Disposal of Documentation: Specific advice should be sought from a legal
practitioner prior to the destruction of any medical record. Legislation guidance regarding the
destruction of medical records can be found in the Archives Act (Tas) 1983.
There are various factors, which dictate the length of time for which health records should be
retained before disposal. Factors such as clinical considerations, possibility of litigation or research
may affect how long records should be retained. (Generally seven (7) years retention of records will
suffice.)
• Nurses’ Personal Professional Journal: Practitioners must also be aware of and practice in
accordance with privacy legislation that may pertain to their practice. The law in this area is
complex and it is not in the scope of this document to provide definitive guidance in this area
Practitioners should obtain further information from their own legal adviser
• Access to Records by Clients/Patients: The Freedom of information Act 1991 provides a legally
enforceable right for clients/patients to access their own records, and to have misleading
information corrected. Application for access of records must comply with the legislative
requirements of the Freedom of Information Act 1991. This legislation applies only to State
agencies and “prescribed authorities” as defined in Section 5 of the Act, and does not apply to
private hospital notes or to doctor’s records held in private rooms.
An exemption is contained within the Act, which allows for denial of access by a client/patient to
their record where the disclosure of the information may adversely affect the physical or mental
health of the client/patient. In such cases, a medical practitioner nominated by the client/patient is
entitled to access the records and may then pass on the appropriate/relevant information to the
clients/patient. The Freedom of Information Act 1991 provides for the accessing of nursing
documentation by clients/patients. Nurses are encouraged to ensure their documentation is
objective, contemporaneous and relevant.
Accurate record keeping and careful documentation is an essential part of nursing practice. The
Nursing and Midwifery Council (NMC 2002) state that ‘good record keeping helps to protect the
welfare of patients and clients’ — which of course is a fundamental aim for nurses everywhere.
You can look at the full Guidelines for records and record keeping by visiting the NMC website ( It
is equally important that you can also communicate by letter and e-mail with other health and social
care professionals, to censure that they understand exactly what you mean.
• Nursing documentation and rerecord keeping: High quality record keeping will help you give
skilled and safe care wherever you are working. Registered Nurses have a legal and professional
duty of care. Record keeping and documentation should demonstrate:

 A full description of your assessment and the given care planned


 Relevant information about your patient or client at any given time and what you did in
response to their needs
 That you have understood and fulfilled your duty of care, that you have taken all reasonable
steps to care the patient or client and that any of your actions or things you filed to do have not
compromised their safety in any way
 A record of any arrangement you have made for the continuing care of a client’.
Investigations into complaints about care will look at and use the patient/client documents and
records as evidence, so high quality record keeping is essential. The hospital or care home, the
NMC, a court of law or the Health Service Commissioner may investigate the complaint, so it
makes sense to get the records right. A court of law will tend to assume that if care has not been
recorded then it has not been given.
Guidelines for Documentation and Record Keeping:
The basic guidelines for good practice in documentation and record keeping apply equally to written
records and to computer held records.
The Nursing and Midwifery Council (NMC 2002) has said that patient and client records should:
• be based on fact, correct and consistent
• be written as soon as possible after an event has happened to provide current (up to date)
information about the care and Condition of the patient or client
• Be written clearly and in such a way that the text cannot be erased’ rubbed out be written in such a
way that any alterations or additions are dated, timed and signed. so that the original entry is still
clear
• be accurately dated, timed and signed, with the signature printed alongside the first entry’ (this is
even more important because your last name may not be very common in the UK)
• not include abbreviations, jargon, meaningless phrases, irrelevant speculation and offensive
subjective statements’
• be readable on any photocopies’
The NMC guidelines clearly state that abbreviations should not be used in patient/client records,
because you will see and hear abbreviations used in medical notes and handover reports, a list of
commonly used ones is provided help you understand what people mean.
The NMC goes onto say that records should:
• Be written, wherever possible, with the involvement of the patient, client or their career.
• be written in terms that the patient or client can understand
• be consecutive’ (uninterrupted)
• identify problems that have arisen and the action taken to rectify them
• Provide clear evidence of the care planned, the decisions made, the care delivered and the
information shared.

Other documentations:
• Letter writing: Letters may be professional, business or private. The private type is obviously easier
to write, but there are, nevertheless, certain basic rules to be remembered
• The envelope:
 It is becoming increasingly common in the UK to put the sender’s name and address on the
back of the envelope, particularly when sending packages and important documents. However,
most people in the UK throw away envelopes as soon as letters are opened, so if you want an
answer you must write your full address on the letter itself.
 It is correct to address people as Mr., Ms, Mrs or Miss with initials and last name (e.g. Miss J
Smith or Mr. O. Masood). Many women prefer to be addressed as Ms, regardless of marital
status, and certainly Ms should be used where you are unsure. A married woman or a widow
may be addressed as Mrs unless she has some other title or is known to prefer Ms. An
unmarried woman may be addressed as Miss. There is a growing tendency to omit the title
completely and simply use the name (Jill Smith or Omar Masood) on the envelope. Other titles,
such as Professor or Dr, should be used if appropriate.
 When writing a professional or business letter to a college, a company, a hotel, a professional
journal, etc., the letter must be addressed to someone. You would, in fact, write to the Principal
of a college, to the Secretary or Manager of a company, to the Manager or Receptionist of a
hotel and to the Editor of a professional journal.
 The address follows the name, in this order:
o The number of the house and the name of the street, or the name of the house with the
street name on a separate line
o Village, town or city
o County (and country if written from abroad)
o Postal code.
As can be seen from the above example, usual practice is to omit punctuation from the details of the
name and address. On word processed or typewritten letters, indentation is no longer used.

The letter:
• The sender’s address is written in full at the top right-hand side of the paper. It is not usual to put
your name there. In care homes and hospitals and other places where official writing paper is
printed, the address, including the telephone number and e-mail address, is either on the tight-hand
side or in the centre
• In private letters the date is usually written below the sender’s address in the order: day, month,
year (e.g. 7 June 2006, or sometimes as 7.6.2006)
• In a professional or business letter, the name and address of the person to whom the letter is written
are placed on the left hand side, at the top, with the date written below
• When you write to an unknown person the letter begins ‘Dear Sir’, or ‘Dear Madam’ if it is to a
woman If you are unsure, write ‘Dear Sir/Madam’
• When you have met the person or corresponded before, the last name is used and the letter begins
with ‘Dear Dr Sanchez’. If you know the person well or they have signed previous letters to you
with their first name it is usual to address them by their first name (e.g. ‘Dear Rao)
• When writing to a friend, one begins ‘Dear John’, ‘Dear Farida’, or ‘My dear Elizabeth’, to a closer
friend
• If the letter begins ‘Dear Sir or Madam’, the ending should be ‘yours faithfully’
• If the letter begins, ‘Dear Ms Steele’ or some other name in a professional or business
correspondence, the ending should be ‘yours sincerely’
• With best wishes’, ‘with kindest regards’ or ‘Yours’ are quite usual endings for letters to friends, or
colleagues who you know well
• Phrases such as ‘yours respectfully’ are no longer used. Nor is it UK practice to use very flowery,
effusive (over the top) language in a professional or business letter. Write clearly and simply and
briefly in a professional or business letter
• Each new subject or aspect of the subject should be dealt with in a separate paragraph. In a
handwritten letter the paragraphs are marked by starting a little distance from the left side, or in
word-processed letters by leaving space between the paragraphs
• It is important to print your name in block letters underneath your signature. as names are often
very difficult to read in handwriting
• In situations where you have written asking for information such as details of a course, the
institution may write to thank you for your interest and ask you to send an envelope with your
address and enough postage stamps, so they can send you the printed material. The request for such
an envelope is usually abbreviated to ‘please send/enclose an SAE’

All comments written at the bedside and communicated to the researchers were condensed and put into
point form. The responses from the telephone questionnaire were analyzed using percentages.
Comments included:

POSITIVE NEGATIVE
• See everything at a glance in front of you • It would be better in more than one
colour (print).
• A better overall picture, as you can see • It would be even more of an
down the page observations correlating improvement if it incorporated even
with fluids. more charts e.g. pain chart.
• Great not to have so many pieces of • Not enough space for intercostal
paper. catheters, have to draw up lines.
• Dispenses with large pieces of paper for • Find it difficult to add fluids across
small amounts of information. instead of vertically.
• Different colors for observations a great • Would like larger area to write
idea, cardiovascular chart is very clear. fluids.
• Definite advantage over ward charts, • Some areas of the chart would be
gives holistic picture of the patient. wasted if the patent was only high
• dependency.
• Very refreshing to try something new. • Prefer graphs for ventilation and
neurological.
• A great starting point for further • One sheet would be better.
improvements.

Importance of documentation:
• Documentation facilitates communication
• Through documentation, nurses communicate to other nurses and care providers their assessments
about the status of clients, nursing interventions that are carried out and the results of these
interventions.
• Documentation of this information increases the likelihood that the client will receive consistent
and informed care or service
• Thorough, accurate documentation decreases the potential for miscommunication and errors
• Documentation promotes good nursing care
• Documentation encourages nurses to assess client progress and determine which interventions are
effective and which are ineffective, and to identify and document changes needs to the care plan
• Documentation can be a valuable source of data for making decisions about finding and resource
management as well as facilitating nursing research, all of which have the potential to improve the
quality of nursing practice and client care
• To meet professional and legal standards
• Documentation is a valuable method for demonstrating that, within the nurse-client relationship, the
nurse has applied nursing knowledge, skills and judgment according to professional standards
• The nurse’s documentation may be used as evidence in legal proceedings such as lawsuits,
coroners’ inquests, and disciplinary hearings through professional regulatory bodies. In a court of
law, the client’s health record serves as the legal record of the care or service provided
Conclusion:
Nursing documentation: a nursing process approach clearly and concisely provides guidelines
for appropriate and careful documentation of care. Accurate documentation shows managed
care companies that patients receive adequate care and health care providers are controlling
costs and resources. In addition, it plays a large role in how third party payers make payment or
denial decisions. This new edition includes the latest changes and trends in nursing
documentation as related to the newly restructured healthcare environment. Special attention
focuses on the latest documentation issues specific to specially settings, such as acute care,
home care, and long-term care, and a variety of clinical specialties, such as obstetrics,
pediatrics, and critical care.

Summary:
 Overview of Documentation.
 Documenting Assessment
 Documenting Nursing Diagnosis and planning
 Documenting Implementation
 Documenting Evaluation
 Legal Aspects of Charting Techniques
 Charting
 Computerization of Nursing Information
 Implementing Changes in Documentation systems
 Maternal Child Documentation
 Critical Care Documentation
 Preoperative Documentation
 Psychiatric and Homecare Documentation
 Long –term Lon€ Care Documentation

References
 Nursing and Midwifery Council (NMC) 2002.Guidelines for records and record keeping.
NMC, London.
 Ellen Thomas E.(1994) Nursing Documentation USA. Lippincott
 Lois White.(2000). Foundations of Nursing. USA Delmar Thomson Learning.
 Tong B.C. and Phipps W (1985). Medical Surgical Nursing: A Nursing Process Approach.
3rd Edition. Mosby Boston.
 Cox H.C., Hinz M.D. and Lubno MA (1989).(Clinical Applications of Nursing Diagnosis).
Williams and Wilkins London; pp 339-397.
 Carpenito Li. (2000). Nursing Diagnosis: Application to Clinical Practice. 7th Edition. J.B.
Lippincott Company New York.