Importance of Documentation Care in Nursing Essay.
This scenario presents a number of problems to the staff nurse. In relation to the sphere of practice, as a D Grade Staff Nurse I have a senior nurse present on the ward, who will be in charge during the shift. This provides me with a source of support and experiential knowledge, and also someone with whom to liaise over any issues which arise. However, as a Registered Nurse I am responsible for my own practice, accountable for all aspects of nursing practice and therefore must act on everything pertaining to practice that should arise. In an ideal situation, the E Grade will act on any information or concerns I bring to her. If she does not, then it is my responsibility to act on these concerns myself. The NMC Code of Conduct (NMC, 2004) requires that all qualified nurses act in the best interests of their patients at all times. The NMC code of conduct also states that all nurses are accountable for their own practice, and must account for their own acts or omissions (NMC, 2004). Importance of Documentation Care in Nursing Assignment.
The focus of this analysis of the scenario is on documentation and the nurse. The nursing literature suggests that the completion of nursing documentation has been one of the most important functions of nurses, even from the beginning of the profesion in the time in the time of Florence Nightingale (Cheevakasemsook et al, 2006). Documentation of nursing care is an important source of reference and communication between nurses and other health care providers (Martin et al, 1999). Documentation is a fundamental component of nursing activities such as assessment and care planning, according to the various models which have been designed for these functions (Nazarko, 2007).Importance of Documentation Care in Nursing Assignment. The importance of proper documentation may also be because it serves multiple and diverse purposes for nurses, for patients, and for the health profession, because current health-care systems require that documentation ensures continuity of care, furnishes legal evidence of the process of care and promotes and facilitates the evaluation of the quality of patient care delivery (Cheevakasemsook et al, 2006).
In this instance, following handover, the first source of information to be checked will be the nursing records and care plans of each patient, as part of an individualised approach to care. The nursing records for Mrs Smith, for example, should provide the medical history and social history which will allow me to provide holistic nursing care. However, one of the problems with nursing documentation, as found in some empirical nursing studies, is that the complexity of nursing documentation does not always allow it to serve its many functions (Cheevakasemsook et al, 2006). However, the medical record is a legal document that tells the story of the patient’s encounter with the nurse and other professional caregivers, and as such should provide a complete and accurate account of his condition and the care he received (Austin, 2006). Whatever the difficulties of the documentation processes concerned here, the documentation should have been complete and correct.
Documentation issues here include the improper recording of the administration of intravenious antibiotics. Given the strong nature of this medication, their specific nature and mode of action which can be tailored to the individual disease following culture and sensitivity tests, and the need to ensure they are given at the correct intervals, particularly as some such drugs can become toxic in larger doses, the proper recording of their administration is a vital part of the administration process. Bjorvell et al (2003) in a study of 377 nurses in Sweden found that nurses believed documentation to be fundamental to nursing practice, in particular, in promoting and ensuring patient safety. Protocols for the administration of intravenous medications exist, which, if followed, should promote safety. Importance of Documentation Care in Nursing Assignment.
For all medications that nurses give to patients, they must know indications, contraindications, dosage parameters and adverse reactions (Austin, 2006). Nurses must always ensure that the ordered medication is appropriate for the patient, and that the prescription is clear and legible (Austin, 2006). And once a nurse has administered a drug, they must monitor the patient for signs and symptoms of drug toxicity or other adverse reactions, and these monitoring activities must be fully documented, including any actions taken on notable findings and the patient’s response to these interventions (Austin, 2006). This creates a record which demonstrates that the nurse met the prescribed standards of patient care when administering medication (Austin, 2006). Two qualified staff should have checked the drug dosage, route and timing, and the prescription against the patient identfication band, and then recorded the adminstration of the antibiotics on the chart and in the patient records. Incomplete records in this instance could be suggestive of improper procedures in the adminstration of this medication, a serious issue which could lead to legal action and professional sanction, even dismissal and loss of registration (Austin, 2006).
Similarly, the issue of the blood transfusion error should be highlighted, because again patient safety is the fundamental point of nursing care. If proper procedures had been followed, this error could not have occurred. Administration of blood and blood products is subject to strict surveillance, and each Trust will have clear guidelines and protocols which govern and support this kind of activity. Checks should have been carried out on collection of the blood – the documentation should have been checked against the blood bag – patient name, number, blood group and type. The blood form, with the number of the blood bag, should have been checked properly. This should have been carried out by two qualified staff. The same checks should have been carried out at the bedside, checked against the patient notes and his identification band. Had the documentation been checked in this way, by two qualified staff, the wrong rhesus factor blood could not have been administered. This demonstrates how correct documentation supports safe nursing practice and facilitates patient safety as well as recording nursing actions. Importance of Documentation Care in Nursing Assignment.
Not only should the mistake be rectified, the doctor in charge of the patient informed and sumoned to examine the patient, and ongoing observations be carried out to ascertain if there are any side effects from the administration of the blood, but all of this should be clearly documented. Further, it should also be documented how this mistake occurred, through an examination of the documentation pertaining to the error and the actions of those who administered the blood. All medically releveant facts realted toan incident should be recorded in the medical records, according to the Trust and ward policies and protocols (Austin, 2006). A critical incident reporting from should also be completed, according to Trust policy, in order to ensure that risk management are informed and actions can be taken to prevent such occurrences in the future. Thus, such a form should also be completed for the percieved drug error. The NMC code of conduct states that nurses should act to identify and minimise risk to the patient or client (NMC, 2004), and this applies to the action taken in the current situation and the potential protection of all clients in the future, in the avoidance of future errors of a similar nature.
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Another error which relates to documentation is the issue of the patient who was discharged inappropriately. It is understandable that the relative should be distressed and should be dealt with sensitively and apologetically. Liaison with management, risk management and any hospital or Trust agencies which deal with patient complaints should commence immediately. The most important issue here is to address the error, and not to question whether or not the error took place. It obviously did, because the patient arrived home in that state, and the usual discharge protocols cannot have been adhered to. If they had been, the discharge documentation should have been complete, and would have been communicated with the receiving district nursing team. The nurse plays a unique and pivotal role in discharge planning, as a key member of a multidisciplinary team (Fielo, 1998) role. If, as Bull and Roberts (2001) suggest, a proper discharge occurs in stages, and can be characterised by involvement of all team members within interacting circles of communication, then this discharge error should not have taken place at all. Therefore, any work done to address this error must examine where communication processes failed, and the documentation here should provide the evidence of where this failure occurred.
Communication is fundamental to discharge planning, both between nurse and patient and between professionals across the divide between hospital and community services (Fielo, 1998), and so the documentation here should have been both individualised and comprehensive, functioning both as a record and as a communication tool. Effective discharge planning is also a vital link for continuity of care (Bull and Roberts, 2001), and so the failure of this process will lead to negative impact for the patient and their carers. Similarly, patient and carer participation is important in discharge planning (McLeod, 2006; Bull and Roberts, 2001). Research by Cleary et al (2003) demonstrates that consumers want information on medication, treatment, awareness of their rights and opportunities to participate in decision making. The nurse engaging in discharge planning also needs to take into account the needs and capabilities of carers (Qualey, 1997). Importance of Documentation Care in Nursing Assignment.
The failure of the discharge planning process in this case therefore has a number of complex effects and may be shown to have failed in a number of key areas. It is also imperative that nurses value the social aspects of patient care and that this is seen as an integral part of the discharge process (Atwal, 2001). There are some ways in which this could be improved, and a close examination of what went wrong might highlight ways in which this could be avoided in future cases. The discharge documentation may need to be adapted to better reflect the processes and knowledge involved (Reed, 2005). This might ameliorate relationships between the acute and community sectors (McKenna and Keeney, 2000), and may prevent these errors occurring in the future. It might also be necessary, from the evidence of the available documents relating to the case, and from the ward rota, to identify who failed to properly discharge the patient so they can be engaged in education and development activities to develop their competence in this area. The documentation used should have served to enhance the ability to deal with this difficult situation (Sollins, 2007) by providing the family with the answers to their questions about what went wrong.
Cheevakasemsook et al, (2006) in their study found that complexities in nursing documentation include three aspects: disruption, incompleteness and inappropriate charting. Of these, this scenario shows occurrences of incomplete documentation, whereby the documentation related to discharge planning has not been completed. Related factors that influenced documentation comprised: limited nurses’ competence, motivation and confidence; ineffective nursing procedures; and inadequate nursing audit, supervision and staff development functions (Cheevakasemsook et al, 2006). These findings suggest that complexities in nursing documentation require extensive resolution and implicitly dictate strategies for nurse managers and nurses to take part in solving these complicated problems (Cheevakasemsook et al, 2006). These are learning points to take forward into future professional development and practice. However, the more immediate needs would be to address the problems associated with these failures. The nurse must act to redress the balance and to minimise, for example, the potential litigation which may arise from this unfortunuate situation. The family are likely to make a formal complaint, and, depending on how this has affected the discharged patient, may even take legal action for compensation. In this instance, the incomplete discharge documentation demonstrates that the required nursing care did not take place (as there is no evidence of it in the records). Therefore, legally, the nurse taking care of this patient will be liable for the errors that have occurred.
There are other issues to be considered, taking the wider view, in perhaps understanding why such errors occurred and how they can be avoided in subsequent cases. Hyde et al (2005) highlight the limitations of the forms of documentation (and the forms of communciation which characterise that documentation) within nursing practice. They suggest that this nursing documentation depicts the domination of reductionist medical models, utilising scientific rationality in linguistic and communication forms, rather than reflecting the holistic nature of nursing practice (Hyde et al, 2005). Therefore the documentation may be at odds with the autonomy of the patient, bringing up issues of control and power, where the documentation may serve to exert and maintain the power of the nurse or the medical profession rather than support the wellbeing of the patient (Hyde et al, 2005). Professional autonomy on the part of nurses demands a degree of mature clinical and ethical judgement in emergent and complex situations, and it is the documentation, if correctly completed, which should also signpost this process of judgement and decision making. But if the documentation is difficult to complete, onerous or time consuming, it may be that it detracts from the quality of patient care and the easy recording of this, rather than supporting it. Documentation provides the legal protection nurses require in modern healthcare practice (Frank-Strombourg et al, 2001). Educating nurses about the principles of documentation and the importance of implementing risk-reduction practices may help guard against liability and ultimately improve patient care (Frank-Strombourg et al, 2001). Perhaps developing better charts and records, in liaison with all staff, might also ameliorate the situation.
The literature demonstrates unequivocally that nurses are the professionals that patients have the most interactions with in the hospital environment (Williams, 1997). The work and competence of the nursing staff is therefore perhaps the most significant factor in determining quality of patient care (Williams, 1997), and so it is vital to ensure that nurses record their practice accurately so that their competence can be audited, and the effectiveness of their practice evaluated. If, as suggested, evidence-based practice is now at the heart of nursing care (DOH, 2001), then documentation will also allow the implementation of evidence based practice, through care protocols and pathways, and through auditing processes and reflective practice which reviews care against the available evidence. Martin et al (1999), in their research of nursing documentation activities, found that good nursing documentation supported the implementation of evidence-based practice. This takes us back to the quality of the documentation processes, and it may be that they are under development – towards evidence-based care pathways or the like, or this kind of thing may need implementing. Importance of Documentation Care in Nursing Assignment.
Utilising alternative modes of documentation may also enhance practice and recording behaviours. Lee (2006) in a study of one computerised documentation system in practice, found that nurses generally viewed the content of the computerized nursing care planning system as a reference to aid memory, a learning tool for patient care, and a vehicle for applying judgement to modify care plan content. This suggests that such tools may do more than simply streamline nurses’ work (Lee, 2006). It may be that using a computerized care plan system can also enhance nurses’ knowledge, experience and judgement of descriptions of patient problems and care strategies (Lee, 2006). It is my opinion that it may also serve to minimise the kinds of errors that have occurred in the assignment scenario.
The nature of the documentation (ie the content and structure) may therefore need to be changed. O’Connor et al (2007) show how new, streamlined nursing charts improved planning and evaluation of care and served promote patient involvement in the care and documentation processes. In reference to the discharge planning incident in particular, this might be an area to develop within the clinical area.
One innovation which supports this is that described by the NHS (2007) in The Essence of Care, which was launched in February 2001, as providing a toolkit to help practitioners to implement a structured approach to sharing and comparing practice, through principles of clinical governance, enabling them to identify the best and to develop action plans to remedy poor practice. This would appear to be a key activity in the longer term to develop from the learning points contained within this problematic scenario. These kinds of benchmarks and guidelines can provide useful guidance, in association with other activities such as evidence-based care pathways and protocols, to develop more streamlined and effective practices. Importance of Documentation Care in Nursing Assignment.
Another point of action is the need to carry out specific empirical research into this area. In a systematic review of research literature to test the hypothesis that care planning and record keeping in nursing practice has no measurable effect on patient outcomes, the authors were unable to identify any robust studies for review (Moloney and Maggs, 1999). This suggests that the potential effects of documentation failures cannot be fully evaluated, anticipated or described without future research. This also underlines the need to ensure the highest possible standards of care are both implemented and fully documented throughout every stage and componenet of nursing practice.
This analysis shows that documentation serves a number of purposes within nursing practice. It records care, demonstrating and communicating what procedures were carried out, when, and why. It rationalises clinical decisions and evaluates clinical and nursing actions. It also allows the direction and planning of care. It provides legal proof that nurses have followed proper protocolsand procedures for the administration of medicines and blood products, for the implementation of medical and nursing orders, and in particular supports complex activities such as discharge planning. Importance of Documentation Care in Nursing Assignment.Lack of proper documentation can indicate that proper procedures were not carried out. Poor documentation can lead to confusion and to patient compromise, whereby a patient may not receive the medication required, or may erroneously receive an overdose. Similarly, the blood error could have had significant consequences, and should not have occurred, given the nature of the procedures involved, and the clear links between safety and existing documentation. These errors point to either a lack of competence in basic nursing procedures, or a lack of care on the part of the staff who made them.
Documentation would also have supported the D grade nurse here when dealing with the problems. The discharge planning errors could have been dealt with more effectively if the documentation had been complete. This would be their primary source of information when dealing with a patient complaint and a complaint from a district nursing colleague. The expectation on all parts that such records will be complete and will answer the questions raised by all parties places the responsibility firmly on the nurse to ensure they properly fulfill this vital part of their role. Nurses can engage in proper documentation of the errors and incidents noted so that they are appropriately and comprehensively dealt with now that the errors have been identified, and so can meet all the professional requirements of their role within this siutation (NMC, 2004). And all staff can learn from these incidents, and be included in processes of research, improvement and development to implement better documentation and care practices in the future. Importance of Documentation Care in Nursing Assignment.
Nursing documentation is considered as an important indicator to develop nursing care. According to patient safety law, nurses have to document nursing interventions (Öhlén, 2015). In Europe, it has been pointed to the attempts to standardize nursing records (Thoroddsen et al.,
2009).
On the global level, the nature of nursing career involves that nurses carry out similar duties including the documentation of patients’ care, assessments and finding and outcome of care (Hearthfield, 1996). In their
study, Moody and Snyder (1995) showed that documentation took about 15-
20% of the nurses’ time. European Scientific Journal January 2016 edition vol.12, No.3 ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431
According to Irving et al (2006), nursing documentation can be
viewed as the record of care planned and or care provided to patients. Importance of Documentation Care in Nursing Essay.
Nursing documentation was described by the College of Registered Nurses
of British Columbia (CRNBC, 2007) as a generated information, written or
electronic, that describes the care or service rendered to individual client or
group of client. In fact it is an accurate account of what has occurred and
when it occurred.
Two studies, Bakken (2007) and Hansebo et al (1999), expressed
their views regarding nursing documentation to involve a description of
nurses tasks, a method for problem solving and decision making as well as a
theoretical or philosophical model of thinking and describing the care
process. Importance of Documentation Care in Nursing Essay.
The reasons for nursing documentation
It is thought that the importance of nursing documentation cannot be
overemphasized. Furthermore, nursing documentation is considered as a way of communication, and presents as an indicator for quality of care (Ammenwerth et al., 2003). Nursing documentation is considered a crucial
phase in the nature of nursing as a career with the purpose of determining the
factors that help nursing process and others that form the bases of nursing decision-making (Karkkaninen and Eriksson, 2003).
It is worth to mention that the perception of nurses towards
documentation implies nursing documentation as a significant step in their
daily practice as well as emphasizing patients safety (Bjorvell et al., 2003). Importance of Documentation Care in Nursing Essay.
Nursing documentation offers various options to enable nurses making
choices regarding decision making for optimal care ( Jefferies et al., 2010).
According to Cheevakasemsook et al (2006), nursing documentation
has the following important aspects which include offering a legal evidence of the medical process and outcomes of care; providing an instrument or tool to assess the quality, efficiency and effectiveness of patient care; giving evidence for several issues such as research, financial and ethical quality assurance purposes; providing the database infrastructure supporting
development of nursing knowledge; and helping in creating benchmarks to
develop nursing education and standards of clinical practice. It has been
argued that optimal use of nursing documentation is likely to achieve if
documentation is accurate (Ellingsen and Munkvold, 2007).
Principles of documentation
Appropriate nursing documentation has various principles including
objectivity, specificity, clearing and consistency, comprehensive, respecting
confidentiality, and recording errors (Chelagat et al.,
European Scientific Journal January 2016 edition vol.12, No.3 ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431
103
Quality of nursing documentation
Documentation is considered as a communication tool to exchange
the information stored in records between nurses and other caregivers
(Urquhart et al. 2009). It is believed that the quality of nursing
documentation plays very important roles in encouraging structured,
consistent and effective communication between caregivers and facilitates
continuity and individuality of care and safety of patients (Bjo¨ rvell et al.
2000, Voutilainen et al.2004). Importance of Documentation Care in Nursing Essay.
Nursing documentation has been defined as the record of nursing care
that is planned and given to individual patients and clients by qualified
nurses or by other caregivers under the direction of a qualified nurse
(Urquhart et al. 2009). Nursing documentation is an attempt to present the
issues that occurred in the nursing process and the information that leads to
decision-making including admission, nursing diagnoses, interventions, and
the evaluation of progress and outcome (Nilsson and Willman 2000,
Karkkainen and Eriksson 2003).
Nursing documentation has other uses such as quality assurance,
legal purposes, health planning, allocation of resources and nursing development and research, and accordingly nursing documentation has to have valid and reliable information and to be compatible with working standards (Idvall and Ehrenberg 2002, Karkkainen and Eriksson 2003,
Urquhart et al. 2009).
The history of nursing documentation has started since the early days
of Nightingale (Gogler et al. 2008). It is worth to mention that nursing documentation was improved with the introduction of the nursing process into the clinical setting (Oroviogoicoechea et al. 2008). The nursing process is regarded as a scientific approach in which critical thinking is used to solve
problems and this approach was introduced into nursing practice and education Yura and Walsh in 1967 (Wang et al., 2011). Importance of Documentation Care in Nursing Essay.
Nursing records are usually of low quality (Wan et al., 2011). Several
studies showed that nursing documentation records were insufficient
regarding the nursing care provided to a patient (Ehrenberg and Birgersson,
2003; Voutilainen et al., 2004; Irving et al., 2006; Mahler et al., 2007;
Oroviogoicoechea, Elliott, and Watson, 2008). It was also indicated that data
was not concisely and clearly presented (Whyte, 2005).
It has been recognized that the traditional paper based documentation does not cope with modern health requirements, and this may due to the nature of manual documentation process in which documentation is often repetitive and manipulation of data is not an easy process (Cheevakasemsook et al., 2006; Yu et al., 2008). Other studies pointed to withdraw backs of paper-based records in which documentation is illegible, lacking information about individualized patient care, containing useless information and missing
European Scientific Journal January 2016 edition vol.12, No.3 ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431
the signatures of care staff (Ammenwerth et al., 2001; Whyte, 2005;
Urquhart et al., 2009).
The use of information technology has witnessed wide use by health care organizations to support care delivery because electronic documentation systems help in data capturing through the use of structured date entry and formalized nursing language (Ehrenberg and Ehnfors, 2001). Electronic documentation systems have the advantages in offering health professionals with increased access to more complete, clear, accurate, legible and up-todate patient information (Helleso and Ruland, 2001; Oroviogoicoechea,
Elliott, and Watson, 2008). Importance of Documentation Care in Nursing Essay.
Conclusion
Nursing documentation is very crucial in health care settings and
reflects various aspects including the awareness level of nurses in their roles
in providing health services in a good quality. Nursing documentation have
two main forms: paper based documentation and electronic based
documentation. Paper based documentation has certain drawbacks such as
lacking the comprehensiveness and clarity. Accordingly, a strong trend to
shift paper based documentation towards electronic documentation has been
witnessed.
Who Has a Role in Documentation?
Firsthand Knowledge
Legislation and Standards of Practice require nurses to document the care they provide to demonstrate
accountability for their actions and decisions. Firsthand knowledge means the professional who documents is
the same individual who provided the care. In situations where two or more people provide care or services,
the nurse who has the primary assignment is expected to document the assessment, interventions and client
response, noting the role of other care providers, as necessary However, the second provider is expected to
review the documentation and to make an additional entry if necessary.
There may be an occasion when a nurse realizes after their shift and they have left for the day that they did
not document care they provided. For example, a nurse leaves for the day and realizes they had forgotten to
document an issue and calls back to the unit to inform their colleagues. In these rare circumstances, another
nurse, if requested can document the information, with the date, time and designation of the person from
which it was received in the client record, as per agency policy.
Designated Recorder
In emergency situations (e.g., cardiac arrest) where it may not be possible for the nurse providing care to
document, it is acceptable to have a designated recorder. Agency policy should support the practice of
designated recorders in these situations.
Client or Family
In some settings, a client or their family members may be
permitted document their observations and the care they
provided in the client record. Agency policy should outline
this process for the client and their family members, as well
as the documentation responsibilities of nurses.
Students
Students are expected to document the care they provide in accordance with agency and academic policies.
Co-signing notes written by students is not acceptable and may add a level of accountability for the nurse
(SRNA, 2011). It may be necessary for the nurse who is acting as the preceptor to document their own
assessment, interventions and evaluations. The need for this extra level of documentation must be based on
agency policy and professional judgment.
Unregulated care providers should
document care they provide. If they are
unable to document their care due to
agency policy, nurses should advocate for
a change to this policy to ensure nurses are
able to meet their professional standards
4
Self-Employed Nurses
Self-employed nurses must adopt a documentation system and develop appropriate policies, including those
related to the storage, retrieval and retention of health records. Both CLPNNS and CRNNS have practice
guidelines to support nurses who are self-employed. You can access these guidelines here:
CRNNS: A Guide for Self-Employed Registered Nurses
CLPNNS: Practice Guideline Self-Employment
Co-Signing and Countersigning Entries
Co-signing refers to a second or confirming signature of a witnessed event or activity (ARNNL, 2010). Cosigning entries made by other care providers is not a standard of practice and when poorly defined, can blur
accountability (CNO, 2008). If two nurses are involved in an assessment or the delivery of care, both should
document according to agency policy. For example, if two nurses are required to hang a unit of packed-cells,
and both must sign the health record, the intent of a co-signature should be clearly stated in policy. In this
case, agency policy could indicate that the co-signature is confirmation that the nurse (co-signee) witnessed
that the correct unit was given to the correct client. Co-signing implies shared accountability therefore the
person co-signing needs to witness or participate in the event (SRNA, 2011).
Countersigning is defined as a second or confirming signature on a previously signed document, which is not
witnessed (SRNA, 2011). This is not best practice and is generally not supported, but may be used as a quality
control process. For example, in a 24-hour chart review, a nurse reviews a chart to determine if all the orders
are accurately transcribed or all required interventions are completed. Countersigning does not imply that the
second person provided the service but it does imply that the person approved or verified that the service or
record was completed. Agency policy and procedure should be in place to support this practice.
Key Elements of Professional Nursing Documentation
All Aspects of the Nursing Process
Nurses should record data collected through all aspects of the nursing process. As a general rule, any
information that is clinically significant should be documented, such as;
Providing Care to Groups
When documenting for groups or communities the documentation should provide a clear picture of:
• The needs or goals of the groups
• The nurse’s actions based on the needs assessment
• The outcomes and evaluations of those actions
Information about individual clients within the group may
be recorded in the individual client’s health record (CRNBC,
2017). Agency policy will direct where this information is
recorded
Plan of Care
Effective client-focused documentation should include a plan of care. A plan of care is a written outline of
care for individual clients and is part of the permanent record. For more information on the plan of care see
the CRNNS Nursing Plan of Care Practice Guidelines or the CLPNNS The Professional Practice Series: The
Nursing Care Plan.
nursing assessment nursing
diagnosis planning implementation evaluation
If the client is receiving services from two
or more agencies or departments that have
separate records (e.g. Health and Justice) it
is important that the nurse follows agency
policy and records the care they provided
in all relevant documents.
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5
Admission, Transfer, Transport and Discharge Information
Accurate and concise documentation on admission, transfer, transport and discharge provides baseline
data for planning subsequent care and follow up. Agency policy should identify expectations on recording
communication between practitioners when a client’s care is transferred. Nursing documentation should
include information on the client’s status at discharge, any instructions provided (verbal and written),
arrangements for follow-up care and evidence of the client’s understanding, and the client’s family
involvement as appropriate.
Client Education
Nurses provide a wide range of client education on a daily basis. Accurate documentation of this education is
essential to enable effective communication and continuity of what has been taught. The following aspects of
client education should be documented in the health record:
• both formal (planned) and informal (unplanned) teaching
• materials used to educate
• method of teaching (written, visual, verbal, auditory and instructional aids)
• involvement of client and /or family
• evaluation of teaching objectives with validation of client comprehension and learning
• any follow up required
Serious Reportable Events (SREs)
An serious reportable event (SRE) or occurrence is an event which is not consistent with the routine, expected
care of a client or the standard procedures in place in a practice setting (Perry, Potter, Stockert & Hall 2017).
Examples include patient falls, medication errors, needle stick injuries, or any circumstance that places clients
or staff at risk of injury. Serious reportable events which involve clients are generally recorded in two places: in
the client’s medical record and in a SRE report, which is separate from the chart.
Documentation of a SRE in the chart should be recorded by the person
who witnessed the event. The documentation should be accurate,
concise, factual, unbiased and should not contain the words “error”,
“incident” or “accident”. The nurse should first document the SRE in
the health record to ensure continuity and completeness, and then
complete a SRE report in accordance with agency policies.
Serious reportable event reports (also called occurrence reports or adverse event reports) are separate from
the client record and are used by agencies for risk management, to track trends and to justify changes to
policy, procedure and/or equipment. Information included in a SRE report is similar to the information included
in a client’s health record, however, the SRE report also includes additional information about the particular
SRE (e.g., “a door was broken” or “this was the fourth such occurrence this week”), which is not directly related
to the care of the client. Agency policy should clearly describe processes necessary to complete a SRE report.
Medication Administration
Agencies should have specific policies and procedures related to the documentation of medication
administration. The general requirements for this type of documentation include:
• Date
• Actual time medications are administrated
• Name(s) of medications
• Route(s) of medications
• Sites of administration when appropriate
• Dosage administered
• Nurses signature/designation
The purpose of a health record
and SRE report differs. Therefore,
for the sake of clarification, the
nurse should avoid documenting
“refer to SRE report” in a client’s
health record.
6
Each individual health care provider (e.g., respiratory therapists, physiotherapists) should sign for the
medications they administer, except in emergency situations. In emergency situations, nurses may sign for
medications administered by other health care providers as long as this is supported by agency policy.
For more information about Medication Administration see the CRNNS Medication Guidelines for Registered
Nurses or the CLPNNS The Professional Practice Series: Medication Administration.
Verbal Orders and Telephone Orders
Authorized prescribers are expected to write orders whenever possible. Verbal orders should only be
accepted in emergent or urgent situations where the prescriber cannot document their medication orders.
Telephone orders should be limited to situations when the prescriber is not present. The prescriber may be
accountable to review and co-sign their verbal or telephone orders as soon as reasonably possible or within
the timeframe indicated in an agency’s policy.
For more information about verbal and telephone orders see the CRNNS Medication Guidelines for
Registered Nurses or the CLPNNS The Professional Practice Series: Medication Administration.
Text and Email Orders
Increasing numbers of health care professionals are using mobile devices to communicate prescriber orders
by text message or email. This type of communication is discouraged due to the risk of violation of confidential
health information and incomplete communication of client status.
Unauthorized disclosure of client’s personal health information (PHI) is a risk because mobile devices can
store and retain data on the device itself. Also, mobile devices are vulnerable to loss and theft because
of their small size and portability (CNPS, 2013). Encryption and the use of strong passwords are the most
effective way to safeguard a client’s PHI. Without encryption, any emails, voicemails, pictures or text could be
inappropriately accessed or disclosed if the mobile device is lost, stolen or inadvertently viewed by another
person.
Vital information related to the context of the client assessment may be lost when using text or email to
communicate. Text can be subject to interpretation and lead to inappropriate, incomplete or insufficient
prescriber orders.
Text or email should not be used for provider convenience; however, if text or email communication is the only
way health professionals can communicate in the best interest of the client, agencies must have policies to
support this practice. Policies, protocols and systems should enable health care practitioners to use secured
wireless devices to interact with each other and to access client records.
Collaboration with Other Health Care Professionals
Interdisciplinary communication and documentation supports interdisciplinary practice and can eliminate
duplication, enhance efficient use of time and enrich client outcomes. Collaborative documentation enables
health care professionals of all disciplines to share the same documentation tools. Examples of such tools are
clinical pathways and integrated interdisciplinary client progress notes.
Nurses need to ensure their documentation within an interdisciplinary tool accurately reflects the unique
contribution of nursing to the care of clients.
When nurses collaborate with members of the interdisciplinary team to develop and/or modify the plan of
care, they should document the following:
• date and time of the contact
• name(s) of the people involved in the collaboration
• information provided to or by health care providers
• responses from health care providers
• orders/interventions resulting from the collaboration
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• the agreed upon plan of action
• anticipated outcomes
For example, if a nurse seeks clarification from a physiotherapist related to mobilization of a client the nurse
should record the reason for seeking clarification, the name of the health care provider responsible for the
clarification, the action they took and the expected outcome.
Date, Time, Signature and Designation
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Documentation in the health record begins with date and time and ends with the recorder’s signature and
designation. Signatures and initials need to be identifiable and follow specific agency policy. Personal initials
can only be used if a master list matching the caregiver’s initials with a signature and designation is maintained
in the health record.
Agency policy needs to support the method in which date and time is documented. For example, is a 24-hour
or 12-hour clock used and what is the consistent written format of the date. A consistent timepiece should be
used to record time (e.g. cardiac monitor). If you are unable to use this timepiece your documentation should
reflect what timepiece you used to record time.
Objectivity vs Subjectivity
Objective information deals with facts or conditions as perceived without distortion by personal feelings,
prejudices, or interpretations (Merriam- Webster Online, 2017). Objective data is observed (e.g., crying,
swelling, bleeding) or measured (e.g., temperature, blood pressure) and includes interventions, actions or
procedures as well as a client’s response.
Subjective data is modified or affected by personal views, experience, or background (Merriam- Webster
Online, 2017). Subjective data may include information provided by a client as well as from the client’s family
members or a friend.
Documentation should include objective statements related to the nursing process. At times it may be
necessary to include subjective statements in the documentation to enhance the understanding of the client’s
care. Subjective information should provide accurate examples of what was said using quotes appropriately
along with identification of the individual who made the statement. For example, client states, “I am pain-free
today” or “I understood the information provided”.
Avoid Generalizations
Avoid generalizations and vague phrases or expressions such as “status unchanged”, “assessment done”,
“had a good day”, “slept well” or “up and about”. Such vague statements are conclusions without supported
facts. Be specific and use complete, precise descriptions of care. The use of words such as “appears”,
“seems”, or “apparently” are not acceptable when used without supporting factual information because they
lack certainty.
Avoid Bias and Labels
Only document conclusions that can be supported by data and avoid value judgments or unfounded
conclusions. Select neutral terminology or describe observed behaviors. For example, rather than stating that
the “client was drunk” it would be correct to state, “noted an odor of alcohol and speech was slurred”. Instead
of noting, “client is aggressive” it would be correct to state, “client has been shouting and using obscene
language”.
Risk Taking Behaviours
Nurses have an ethical responsibility to respect a client’s informed choice, even if these choices may be risky
to their overall health. The nurse must document the objective data related to the risk taking behaviours and
avoid placing a value judgment on the behaviors. The nurse should also document information they provide to
the client about the risk taking behaviour and any potential consequences of the behavior. It is not acceptable
to document the client as “non-compliant”. Instead, the nurse should document the objective data that
describes this behavior.
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If the risk taking behavior results in a situation in which mandatory reporting must occur, the nurse is required
to follow the legislation and document appropriately.
Legibility and Spelling
Correct spelling and legibility of nursing documentation demonstrates attention to detail and nursing
competence. Misspelled words or illegible entries can result in misinterpretation of information and could
result in client harm. Spelling errors can result in serious treatment errors. For example, the names of certain
medications, such as digitoxin and digoxin.
All entries in a paper-based system should be written legibly in accordance with agency policy related to the
type and colour of writing instrument and the colour of paper used.
Blank (White) Space
Blank or white space in paper-based documents should be avoided as this presents an opportunity for others
to add information unknown to the original author. An accepted practice is to draw a single line completely
through the white space, including before and after your signature. Fill in all blocks or spaces on flow sheets
with the agency approved symbol or comment.
Abbreviation, Symbols and Acronyms
The use of abbreviations, symbols or acronyms can be an efficient form of documentation if their meaning
is well understood. Abbreviations and symbols that are obscure, obsolete, poorly defined or have multiple
meanings can lead to errors. Use only those abbreviations, symbols and acronyms on a current agencyapproved list.
Click here to review the list of error prone abbreviations developed by the Institute of Safe Medication
Practice.
Errors and Changes
Inaccurate documentation can result in inappropriate care decisions and client injury. Errors must be corrected
according to agency policy. The content in question must remain clearly visible or retrievable so that the
purpose and content of the correction is clearly understood. If an error occurs in paper-based documentation,
do not make entries between lines, do not remove anything (e.g., monitor strips, lab reports, requisitions,
checklists), and do not erase or use correction products, stickers or felt pens to hide or obliterate an error. A
generally accepted practice to correct an error in a paper-based system is to cross through the word(s) with
a single line, above the line write “mistaken entry” and insert your initials, along with the date and time the
correction was made and enter the correct information.
To protect the integrity of the health record, changes or additions need to be carefully documented. Never
remove chart pages. Entries should not be re-copied or removed because of a documentation error.
Client Care Provided Through Electronic Means
Today in Nova Scotia many agencies have moved towards
electronic means of providing many aspects of care. Electronic
documentation is now part of the everyday care of many clients.
This could include entering requests for tests and consultations,
reporting diagnostics testing, or documenting care provided.
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 paper-based systems, documentation in electronic health
records must be comprehensive, accurate, timely, and clearly identify who provided what care. Entries are
made by the nurse providing the care and not by other staff. Entries made and stored in an electronic health
record are considered a permanent part of the record and may not be deleted. Client information transmitted
electronically must be stored (electronically or in hard copy) and, if relevant, may be subject to disclosure in
legal proceedings.
Failing to correct an error appropriately
(according to agency policy) or correcting
or modifying another’s documentation
may be interpreted as falsification of a
record. Falsifying records is considered
professional misconduct.
9
Agencies need to have clear policies and guidelines to address these challenges and other issues related to
documentation for electronic health records. Nurses must advocate for agency policies/guidelines that reflect
and support quality, evidence-based practice. Agency policies related to electronic documentation should
clearly indicate how to:
• correct documentation errors and/or make ‘late entries’
• prevent the deletion of information
• identify changes and updates in a health record
• protect the confidentiality of client information
• maintain the security of a system (e.g., regularly changing passwords, issuing access cards, virus protection,
encryption, well maintained firewalls)
• track unauthorized access to client information
• use a mixture of electronic and paper-based methods, as appropriate (policy should ensure continuity of care
is maintained)
• back-up client information
• document in the event of a system failure
• obtain access to a specific group or area of information
Using Fax Technology to Transmit Client Information
Facsimile (fax) transmission of client information between health care providers is convenient and efficient. In
spite of this there is significant risk to the confidentiality and security of information transmitted via fax due to
the possibility of transmitting to unintended recipients. Agency policy should guide nurses in the acceptance
and transmission of faxes for the purposes of client care.
The confidentiality and security of transmitting client information via fax can be enhanced by:
Guidelines Rationale
Locate fax machines in secured areas away from
public access.
Decreases the likelihood of an unintended breach of
client confidentiality.
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.
Carefully check activity reports to confirm successful
transmission.
Ensures that the fax was sent and is not sitting in the
queue to be resent or accessed by someone else.
Include a cover sheet with a Confidentiality
Statement that identifies the fax document as
confidential and instructs unintended recipients to
immediately destroy the document without reading it.
This is a safeguard that make the unintended
recipient accountable for any actions they may take
with information incorrectly sent to them.
Advocate for secure and confidential fax transmittal
systems and policies.
This is an important leadership action that contributes
to quality practice environments.
Client information received or sent by fax is a form of client documentation and should be stored electronically
or printed in hard copy, appropriately labeled with the necessary client information and placed in the client’s
health record. Faxes are part of the client’s permanent record and can be subject to disclosure in legal
proceedings.
E-mail
The use of electronic mail (e-mail) transmission by health care agencies and health care professionals is
10
becoming more widespread because of its speed, reliability, convenience and low cost. However, like faxes,
there is significant risk to the security and confidentiality of e-mail messaging. Messages can inadvertently
be read by an unintended recipient and while the message can be erased from the local computer, they
are never deleted from the central server and could be retrieved by unauthorized personnel. It is not
recommended as a method for transmitting clients’ health information.
Guidelines Rationale
Obtain client consent before transferring health
information by e-mail as dictated by policy.
Even with safeguards, transmitting information by
email has a higher risk. The client should be informed
about the process and any potential risks.
Transmit e-mail using special security software (e.g.,
encryption, user verification or secure point-to-point
connections).
Encryption safeguards against hacking and
unauthorized persons from accessing client
information.
Never allow anyone else access to your password
for e-mail.
Sharing passwords is a risk prone activity because it
allows access to client information under your name.
Nurses that share their passwords or do not take
reasonable steps to protect their passwords may be
held accountable for any activity in their name.
Check that the e-mail address of the intended
recipient(s) is correct prior to sending.
Decreases the likelihood of an unintended breach of
client confidentiality.
Ensure transmission and receipt of e-mail is to a
unique e-mail address.
Maintain confidentiality of all information, including
that reproduced in hard copy.
Locate printers in secured areas away from public
access.
Retrieve printed information immediately.
Include a confidentiality warning 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.
This is a safeguard that make the unintended
recipient accountable for any actions they may take
with information incorrectly sent to them.
Never forward an e-mail received about a client
without the client’s written consent.
The client must grant permission for their information
to be shared with others.
Advocate for secure and confidential e-mail systems
and policies.
This is an important leadership action that contributes
to the quality practice environments.
Telenurisng
Giving telephone advice is not a new role for nurses. What is new is the growing number of people accessing
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 support self care or to provide health services. Telenursing is subject to
the same principles of client confidentiality as all other types of nursing care.
Nurses that 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. Minimum documentation includes
the following:
• date and time of the incoming call (including voice mail messages)
• name, telephone number and age of the caller, if relevant (when anonymity is important, this information may
11
be excluded)
• reason for the call, assessment findings, 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
For further information on telenursing see the CRNNS Telenursing Practice Guidelines or the CLPNNS
Telenursing document.
When timing matters
Timely, Chronologically and Frequently
Documentation should occur as close as possible to the time of care to enhance credibility and accuracy of
health care records (CARNA, 2013). Documentation should never be completed before it actually takes place.
Documenting events in the chronological order is important, particularly in terms of revealing changing
patterns in a client’s health status. Documenting chronologically also enhances the clarity of communications,
regarding the care provided, the assessment data, and outcomes or evaluations of that care (including client
responses).
The frequency and amount of detail required in documentation is generally dictated by a number of factors,
including:
• agency policies and procedures
• complexity of a client’s health problems
• degree to which a client’s condition puts the client at risk
• degree of risk involved in a treatment or component of care
While agency policies on documentation should be followed to maintain a reasonable and prudent standard
of documentation, nursing recording should be more comprehensive, in-depth and frequent if a client is very
ill, very unpredictable or exposed to high risk (Canadian Nurses Protective Society, 2007, p.2).
The following table demonstrates how as clients change the frequency of documentation should also change:
LOW MEDIUM HIGH
ACUITY
COMPLEXITY
VARIABILITY
FREQUENCY OF
DOCUMENTATION
Late entries
As stated, documentation should occur as soon as possible after an event has occurred. When it is not
possible to document at the time of or immediately following an event, or if extensive time has elapsed, a
late entry is required. Late entries or corrections incorporating omitted information in a health record should
be made only when a nurse can accurately recall the event or care provided. Late entries must be clearly
identified, individually dated and follow agency policy. They should reference the actual time recorded as well
as the time when the care/event occurred and must be signed by the nurse involved. If extensive time has
elapsed between the care and the documentation entry, seek guidance from your employer before adding
notes (CRNBC, 2017)
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Conclusion
Nurses should recognize that the documentation of their nursing decisions and actions is equally as valuable,
professionally and legally, as the direct care provided to clients. Quality documentation is an important
element of nursing practice, essential to positive client outcomes and a key component of meeting their
Standards of Practice.
References:
Agneta Öhlén (2015). ADVANCED HOME CARE NURSES' EVERYDAY
PRACTICE. PhD thesis, Karolinska Institute, Stockholm, Sweden.
Ammenwerth E, Eichstadter R, Haux R, Pohl U, Rebel S, Ziegler S. A
(2001). Randomized Evaluation of a Computer-Based Nursing
Documentation System. Methods inf. med., 40: 61-68.
Ammenwerth, E., Mansmann, M., Iller, C., Eichstädter, R. (2003). Factors
affecting and affected by user acceptance of computer-based nursing
documentation: results of a two-year study. Journal of the American Medical
Informatics Association, 10(1), 69-84. Importance of Documentation Care in Nursing Essay.
Bakken, S. (2007). Building standard-based nursing information systems.
Washington, DC: Pan American Health Organization.
Bjo¨ rvell C., Thorell-Ekstrand I and Wredling R (2000). Development of an
audit instrument for nursing care plans in the patient record. Quality in
Health Care 9, 6–13.
Bjorvell, C., Thorell-Ekstrand, I., Wredling, R. (2003). Prerequisites and
consequences of patient records as perceived by a group of registered nurses.
Journal Of Clinical Nursing, 12, 206-214.
Cheevakasemsook A, Chapman Y, Francis K, Davis C (2006). The study of
nursing documentation complexities, Int J Nurs Pract., 12:366 -374.
CRNBC (2007). Nursing Documentation. Crnbc, 151, 1-24.
European Scientific Journal January 2016 edition vol.12, No.3 ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431
105
Dinah Chelagat, Tecla Sum, Millicent obel, Alex Chebor, Robert Kiptoo,
Priscah Bundotich-Mosol (2013). Documentation: Historical Perspectives,
Purposes, Benefits and Challenges as Faced by Nurses. International Journal
of Humanities and Social Science, 3 (16): 236-240.
Ehrenberg A, Birgersson C (2003). Nursing documentation of leg ulcers:
adherence to clinical guidelines in a Swedish primary health care district.
Scand J Caring Sci., 17: 278-284.
Ehrenberg A, Ehnfors M (2001). The accuracy of patient records in Swedish
nursing homes: congruence of record content and nurses' and patients'
descriptions. Scand J Caring Sci., 15: 303-310.
Ellingsen, G., Munkvold, G. (2007). Infrastructural arrangements for
integrated care: implementing an electronic nursing plan in a psychogeriatic
ward. International Journal of Integrated Care, 7, 1-11.
Gogler J., Hullin C., Monaghan V. Searle C (2008). The chaos in primary
nursing data: good information reduces risk. HIC 2008 Australia’s Health
Informatics Conference ISBN 978 0 9805520 0 3.
Hansebo, G., Kihlgren, M., Ljunggren, G. (1999). Review of nursing
documentation in nursing home wards-changes after intervention for
individualized care. Journal of Advanced Nursing, 29, 1462-1473.
Hearthfield M (1996). Nursing documentation and nursing practice: a
discourse analysis. Journal of Advanced Nursing, 24, 98–103.
Helleso R, Ruland CM (2001). Developing a module for nursing
documentation integrated in the electronic patient record. J Clin Nurs, 10:
799-805. Importance of Documentation Care in Nursing Essay.
Idvall E. and Ehrenberg A. (2002). Nursing documentation of postoperative
pain management. Journal of Clinical Nursing 11, 734–742.
Irving K, Treacy M, Scott A, Hyde A, Butler M, MacNeela P (2006).
Discursive practices in the documentation of patient assessments. J Adv
Nurs, 53: 151-159.
Jefferies, D., Johnson, M., Griffiths, R. (2010). A meta-study of the
essentials of quality nursing documentation. International Journal of Nursing
Practice, 16(2), 112-124.
Karkkainen O. and Eriksson K. (2003). Evaluation of patient records as part
of developing a nursing care classification. Journal of Clinical Nursing 12,
198–205.
Mahler C, Ammenwerth E, Wagner A, Tautz A, Happek T, Hoppe B,
Eichstadter R (2007). Effects of a computer-based nursing documentation
system on the quality of nursing documentation. J Med Syst, 31: 274-282.
Moody, L., Snyder, P. (1995). Hospital provider satisfaction with a new
documentation system. Nursing Economics, 13, 24-31.
Nilsson U.B. and Willman A (2000). Evaluation of nursing documentation.
Scandinavian Journal of Caring Sciences 14(3), 199–206.
European Scientific Journal January 2016 edition vol.12, No.3 ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431
106
Ning Wan, Ping Yu, David Hailey, Deborah Oxlade (2011). Developing
Measurements of Quality of Electronic versus Paper-based Nursing
Documentation in Australian Aged Care Homes. electronic Journal of Health
Informatics, 6(1): 1-6.
Ning Wang, David Hailey, Ping Yu (2011). Quality of nursing
documentation and approaches to its evaluation: a mixed-method systematic
review. Journal of Advanced Nursing 00(0), 000–000. doi: 10.1111/j.1365-
2648.2011.05634.x
Oroviogoicoechea C, Elliott B, Watson S (2008). Review: evaluating
information systems in nursing. J Clin Nurs, 17: 567-575.
Thoroddsen A, Saranto K, Ehrenberg A, Sermeus W. (2009) Models,
Standards and Structures of Nursing Documentation in European Countries.
Study of health care technology information;146:327-331.
Urquhart C, Currell R, Grant MJ, Hardiker NR (2009). Nursing record
systems: effects on nursing practice and healthcare outcomes. Cochrane
Database of Syst Revi. Issue 1.
Voutilainen P, Isola A, Muurinen S (2004). Nursing documentation in
nursing homes – state-of-the-art and implications for quality improvement.
Sand J Caring Sci., 18: 72-81.
Whyte M (2005). Computerised versus handwritten records. Paediatric
Nursing, 17:15-18.
Yu P, Hailey D, Li H (2008). Caregivers’ acceptance of electronic
documentation in nursing homes, Journal of Telemedicine and Telecare., 14:
261-65. Importance of Documentation Care in Nursing Essay.