DOCUMENTATION

Prepared by
Mohd Basel
Raed L.Shana`ah
TABLE OF CONTENTS

Introduction
Purpose of Documentation
Communication
Accountability
Legislative requirements
Quality improvement
Research
Funding and resource management
Core Standards for Documentation
Meeting Core Standards
Documenting professional practice
Documentation forms
Documentation content




Timing
Date, time, signature and designation
Documentation methods


Information/knowledge management
Security and confidentiality
Other records
Maintaining a Quality Practice Setting
Conclusion

Introduction
Documentation in the health record is an integral part of safe and
effective nursing practice. Clear, comprehensive and accurate
documentation is a record of the judgment and critical thinking
used in professional practice and provides an account of nursings
unique contribution to health care.

Effective communication requires that nurses review prior
documentation and do their own documentation in a timely
manner.
The standards in this publication outline nurses professional
accountability in record keeping.

They describe the expectations for documentation and apply to all
nurses in direct practice, regardless of the method of
documentation or how it is stored.
A standard is an authoritative statement that sets out the legal and
professional basis of nursing practice.


All standards of practice:
provide a guide to the knowledge, skills, judgment and
attitudes needed to practice safely
describe what each nurse is accountable and responsible
for in practice
represent performance criteria for nurses
interpret nursing scope of practice to the public and other
health care professionals
stimulate peer feedback
encourage research to validate practice
generate research questions that lead to improvement of
health care delivery; and
aid in developing a better understanding and respect for the
various and complementary roles that nurses have.

Nurses should also be aware of the legislative requirements
regarding documentation that may apply to their particular
practice setting. Nurses may need to consult their professional
associations and legal counsel to clarify these legislative
requirements. This document also provides information on quality
practice settings that promote nurses ability to meet these standards.
Current and accessible documentation systems, processes and policies
can support nurses in meeting these standards and providing
professional practice . Effective documentation policies and practice
take into consideration who the clients are, client needs and available
resources. Where clear and effective policies and practices do not exist
in the workplace, nurses need to advocate for them


.
This document can be used by nurses and students who are
learning acceptable standards of practice or as part of Reflective
Practice. It can also be used as a review for staff being oriented to
new positions. Employers can use the document to ensure that
their workplace support nurses meeting these standards.
Purpose of Documentation
Communication
Documentation is fundamentally communication that reflects the
clients perspective on his/her health and well-being, the care
provided, the effect of care and the continuity of care. All health
care providers need ongoing access to client information to
provide safe and effective care and treatment.
Effective documentation allows nurses and other care providers
to communicate about the care provided and to assist clients to
make future care decisions. Good documentation also enables
care providers to use current and consistent data, problem
statements, diagnoses, goals and strategies to facilitate continuity
of care. For example, health-teaching strategies that are clearly
identified and documented when implemented enable other
nurses to continue the health teaching with the client. Accurate
documentation also reflects the effectiveness of the care provided.



Clear, complete and accurate documentation in a client health
record provides a reliable, permanent record of client information.
Health records may be paper documents or electronic documents,
such as computerized records, audio or video tapes, e-mails,
faxes or images. Although the documentation is often done by
nurses and care providers, there are situations in which the client
and family may document care in order to communicate with the
members of the health care team.
Accountability
The health record demonstrates nurses accountability and gives
credit to nurses for their professional practice. It is used to
determine responsibility and resolve questions or concerns
about the provision of care. The nurses documentation may be
used in legal proceedings, such as lawsuits, coroners inquests
and discipline hearings at CNO.
Legislative requirements

Nurses are required to make and keep records of their
professional practice in accordance with the professions
generally accepted standards of practice.
Legislation may further identify specific content that must be
maintained.
Nurses need to consult legislation related to their area of
practice and their employment settings. In addition, failing to
keep records as required, falsifying a record, signing or
issuing a document that the member knows includes a false or
misleading statement
and giving information about a client without consent.
Nurses in independent practice have additional requirements for
storage and retrieval of documentation.
Quality improvement
Information from the health record is often used to evaluate
professional practice during quality improvement processes,
such as performance reviews, chart audits, accreditation,
legislated
inspections and board reviews. Individual nurses can use
outcome information or information from a critical incident to
reflect on their practice and make needed changes based on the
evidence.

Clear, complete and accurate documentation facilitates the
evaluation of the clients progress toward desired outcomes.

It also enables nurses to identify and address areas that need
improvement. Poor documentation provides incomplete or, in the
worst case, no written evidence of the quality of care provided.
Research
Health records can be a valuable source of data for health
research. From a nursing perspective, health records can be
used to assess nursing interventions and evaluate client
outcomes, as well as to identify care and documentation issues.
Accurately recorded information is essential to provide accurate
research data. Through research, nurses can improve nursing
practice.
Funding and resource management
Data from health records can identify the type and amount of
care that clients need, the care and services provided, and the
efficiency and effectiveness of that care. Any of these factors
may affect funding and resource allocation. Workload or client
classification systems are best derived as byproducts of client
documentation.
Nurses are accountable for accurately documenting data related
to client care, workload, and classification.







Core Standards for Documentation
This section outlines the core documentation standards for nurses
in direct practice in all practice settings. These standards apply for
all documentation systems and methods used.
These are the minimum expectations regarding nursing
documentation. Individual employers, employment sectors (e.g.,
long-term care) or legislation may require more specific
documentation. In these situations, nurses are expected to fulfill
these requirements.
Records must be an accurate, true and honest account of what
occurred and when it occurred.
The documentation method should allow information to be
organized in such a way that it presents a clear picture of the
clients needs, the nurses actions and the clients response.

A nurse maintains documentation that is:

clear, concise and comprehensive
accurate, true and honest;
relevant;
reflective of observations, not of unfounded
conclusions
timely and completed only during or after giving
care
chronological
complete record of nursing care provided,
including
assessments, identification of health issues, a plan
of care, implementation and evaluation
legible and non-erasable
permanent
retrievable
confidential;
client-focused; and
completed using forms, methods, systems
provided or, in independent practice, using
practitioner-created forms, methods and
systems consistent with these standards
A nurses documentation:
includes date and time of the care or the event, and the
recording
of when it is a late or forgotten entry
identifies who provided the care;
contains meaningful information, and avoids meaningless
phrases
such as good night, up and about, or usual day;
includes what was observed and avoids
statements such as appears to and seems to when
describing
observations;
includes signatures or initials, and professional designation; and
avoids duplication of information in the health
Record.

Meeting Core Standards























A nurse meets the standards by:
documenting an assessment of the clients health status and
situation/circumstances
ensuring that client preferences for care and outcomes guide
the development of any written plan of care
documenting consent when the nurse proposes a treatment
or intervention
documenting the implementation of the care plan and/or the
action(s) taken
documenting an evaluation of nursing strategies and client
outcomes
documenting independent and collaborative actions
(e.g., those actions ordered by a physician);
advocating for policies and procedures that are
clear and consistent with documentation Standards and
familiarizing her/himself with relevant prior
documentation.

A nurse meets the standards by:

documenting assessment of the needs
documenting purpose, objectives or expected outcomes of
any meetings
documenting the plan or approach to be used
documenting interventions used
documenting an evaluation of interventions and outcomes
documenting advice, care or services provided to individuals
within groups, communities or populations, using the
standards for individual clients; and
advocating for clear documentation procedures that are
consistent with CNO standards.






Documentation forms
Effective documentation forms provide a framework and guide
documentation. To remain effective, forms often require regular
review and revision. This review process takes into account
beliefs and values about health and organizational policy, as well
as external factors such as legislation. For example, a facility that
values client perception of his/her health as an important aspect of
a complete assessment will have a form that includes space for
this information. (For information on documentation methods and
formats)
Worksheets and Kardexes
Nurses use worksheets to organize the care they provide, and to
manage time and multiple priorities. Kardexes are a
communication tool used to convey the clients current orders as
well as upcoming tests or surgery, diet, etc.
Kardexes and worksheets may be in paper or electronic format.
The information they contain may be erasable as long as the
permanent health record reflects the nursing assessment, the
care provided and the outcome(s). The permanent health record
should also contain information on changes in a clients condition
and care. When the Kardex is the only documentation of the
clients care plan, it is kept as part of the permanent record and
should not be erased.

A nurse meets the standards by:

updating Kardex information regularly;
ensuring that temporary worksheets are shredded when
no longer in use; and
ensuring that relevant client care information on a Kardex
or worksheet is captured in the permanent health record.




Care plans
Care plans are written outlines of care for individual clients. They
are part of the permanent health record. Effective care plans are
up-to-date and clearly identify the needs and wishes of the
client.
When the care plan is not evident in the documentation, the
nurse should ensure that a separate formal plan of care is
retained.

A nurse meets the standards by:

keeping the care plan clear, current and useful;
and
individualizing care plans to meet the needs
and wishes of individual clients.

Flow sheets and checklists
Flow sheets document routine care and frequently recorded
information (e.g., activities of daily living, vital signs, intake and
output). They are part of the permanent record and can be used
as evidence in a legal proceeding. To ensure that accountability
is clear when using initials on a flow sheet, a master list
matching the initials to the caregiver is needed. Check
marks may be used as long as it is clear who provided the care
or performed the assessment.
A nurse meets the standards by:
ensuring that every entry clearly identifies the nurse
avoiding the duplication of information elsewhere
documenting the ongoing assessment, plan and evaluation of
care elsewhere as required and
advocating for forms that are consistent with
the CNO documentation standards


Monitoring strips

All relevant assessment data needs to be retained in the health
record, including monitoring strips, such as cardiac, fetal,
thermal or blood pressure testing.

A nurse meets the standards by:

documenting on the monitoring strip the clients name
and/or identification code, and the date and time; and
advocating to have strips retained as part of the permanent
record.
Documentation content

This section explains the type of information that nurses should
document in the health record to ensure that it is clear, concise
and comprehensive. All entries should be accurate, true and
honest. In this way, the health record reflects the nurses
contribution to health care and their accountability.
It gives credibility of professional practice, is a legal document,
allows for effective communication among care providers and
ensures client safety.
When nurses documentation meets these standards, it reflects
that nurses have met their professional and legislative
requirements.

Assessment
Documenting the assessment of a client includes recording the
subjective and objective data. Objective data can be observed
(e.g., swelling, bleeding, crying) or measured (e.g., heart
rate, blood pressure, temperature) and include interventions,
actions or procedures and the client's response.
An assessment may also include subjective data such as
statements or feedback from the client. Subjective data are
clearly identified as such by using quotation marks or other
marks to distinguish it from objective data.
Thirdparty information
Nurses may obtain relevant information about a client or an
incident from another person, such as the clients family member
or friend. Nurses may also learn information about a third party
that is relevant to the client. For example, the mother of a
pediatric client may indicate that her husband is often drunk
when he visits. In these situations, nurses document the
information,if it is relevant, including the source of information.


Collaboration with care providers
Unfounded conclusions
Abbreviations and symbols
Documenting for others
Co-signing entries
Telephone nursing care
Timing
Order of entries
Information documented during or immediately after care is
provided or an event has occurred is considered more reliable
than information recorded later, based on memory. Chronological
entries present a clear picture of events and facilitate better
communication among care providers.

Forgotten or late entries, errors and omissions
Date, time, signature and designation
Documentation methods
The documentation method used by a practice setting should
reflect client care needs and the context of practice. Some
facilities/agencies may combine elements of different
documentation methods and formats to document care
effectively.
Regardless of the method of documentation used, the health
record must present a clear picture of the nurses assessment,
actions and outcomes. Common documentation methods include
charting by exception, critical path/variance analysis (care
mapping), focus charting, SOAP/ SOAPIER and narrative
documentation.
Electronic health records
Information/knowledge management
Security and confidentiality
Conclusion
Documentation is an integral part of professional nursing practice and
provides an account of nursings unique contribution to health care.
When nurses meet the standards and expectations outlined in this
document,they are meeting their professional obligation to
communicate client health information, demonstrate professional
accountability and meet legislative requirements. Meeting these
standards also ensures that their documentation can facilitate quality
improvement, research, funding and resource management.
Finally, by adhering to these standards, nurses are meeting their
professional obligations as self-regulated health professionals to
maintain documentation that is clear, concise and comprehensive, and
is also accurate, true and honest.
Do's and Don'ts of Nursing Documentation
Do's
Check that you have the correct chart before you begin writing.
Make sure your documentation reflects the nursing process and
your professional capabilities.
Write legibly.
Chart the time you gave a medication, the administration route,
and the patient's response.
Chart precautions or preventive measures used, such as bed
rails.
Record each phone call to a physician, including the exact time,
message, and response.
Chart patient care at the time you provide it.
If you remember an important point after you've completed your
documentation, chart the information with a notation that it's
a "late entry." Include the date and time of the late entry.
Document often enough to tell the whole story.
Dont's

Don't chart a symptom, such as "c/o pain," without also charting
what you did about it.
Don't alter a patient's record - this is a criminal offense.

Don't use shorthand or abbreviations that aren't widely accepted.

Don't write imprecise descriptions, such as "bed soaked" or "a
large amount."
Don't chart what someone else said, heard, felt, or smelled
unless the information is critical. In that case, use quotations
and attribute the remarks appropriately.

Don't chart care ahead of time - something may happen and you
may be unable to actually give the care you've charted.
Charting care that you haven't done is considered fraud.




































QUESTIONS

?