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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
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
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
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
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
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.
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
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
• 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
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
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
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
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.