Documentation for Registered Nurses

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Documentation Guidelines for

Registered Nurses

September 2006


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Approved by the College and Association of Registered Nurses of Alberta ProvincialCouncil, September 2006.

Permission to reproduce this document is granted; please recognize CARNA.

College and Association of Registered Nurses of Alberta

11620 168 StreetEdmonton, AB T5M 4A6

Phone: (780) 451-0043 or 1-800-252-9392 (Canada-wide)Fax: (780) 452-3276E-mail: [email protected] Website: www.nurses.ab.ca


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TABLE OF CONTENTS Introduction....................................................................................................................... 1

Part 1: Purposes of Documentation................................................................................. 2Communicating and Providing Continuity of Care ........................................................ 2Accountability................................................................................................................. 2Legal Implications of Documentation ............................................................................ 2Providing Quality Improvement and Risk Management ................................................ 3Facilitating Evidence-Based Practice ............................................................................. 3

Part 2: Guidelines for Documentation ............................................................................ 41. Objective/Factual Documentation .............................................................................. 42. Timeliness ................................................................................................................... 43. Use of Space ............................................................................................................... 54. Use of Abbreviations .................................................................................................. 55. Follow-up.................................................................................................................... 56. Correcting Errors ........................................................................................................ 57. Recording Medication Administration ....................................................................... 68. Recording Assistance with Care ................................................................................. 69. Designated Recorder in Emergency Situations........................................................... 610. Clarification of Orders.............................................................................................. 611. Recording a Telephone Conversation with a Client ................................................. 612. Interactions with other Health-care Professionals .................................................... 713. Client Education........................................................................................................ 714. Documenting an Incident in the Health-care Record................................................ 7

Part 3: Documentation Systems and Methods ............................................................... 9E-health Records............................................................................................................. 9Methods of Documentation........................................................................................... 10

Summary.......................................................................................................................... 12

References........................................................................................................................ 13

Appendix A...................................................................................................................... 14Comparing Health-care Recording Systems.....................................................................

Appendix B ...................................................................................................................... 15Legislation - Nursing Documentation...............................................................................


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DOCUMENTATION GUIDELINES FORREGISTERED NURSES

INTRODUCTION Quality documentation and reporting are necessary to enhance efficient, individualizedclient care (Potter, Perry, Ross-Kerr, & Wood, 2006). Regardless of the format used todocument, the client 1s health-care record is a formal, legal document that details aclients care and progress. Differences in how client health-care records are kept existacross the multiple settings in which registered nurses (RNs) practice, and each clientcare population has its own unique characteristics and expectations. Still, the foundational principles of nursing documentation apply to every type of documentationin every practice setting.

Documentation is not separate from care and it is not optional. It is an integral part of registered nurse practice, and an important tool that RNs use to ensure high-quality clientcare. The term documentation as used in these guidelines refers to:

any written or electronically generated information about a client that describes client status or the care or services provided to that client.

The purpose of this document is to provide guidance to RNs that will assist them inproducing clear, accurate and comprehensive accounts of client care within any setting.It is organized in three parts.

Part 1 discusses the purposes and legal implications of documentation.

Part 2 outlines documentation guidelines, which support quality health-care recordkeeping and assist registered nurses in the provision of safe, ethical and effective care inevery practice setting.

Part 3 addresses systems and methods of documentation for registered nurses.

These guidelines are based on the College and Association of Registered Nurses of Alberta (CARNA) Nursing Practice Standards (2003), which outline the expectations forsafe, competent and ethical practice for registered nurses in Alberta. In CARNAsNursing Practice Standards, indicator 2.6 states the registered nurse documents timely,accurate reports of data collection, interpretation, planning, implementing and evaluatingnursing practice (CARNA, 2003) . Thus, the quality of documentation is a reflection of the standard of professional practice and an indicator of the skilled and safe practitioner.

1 The term client can refer to patients, residents, families, groups, communities and populations.


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Quality documentation provides specific information (who, what, how and why) aboutthe actual care the registered nurse provided and a record of the clients response to thatcare. It assists others in confirming that the RNs care was competent and safe, metacceptable standards and procedures, was provided in a timely manner, and wasconsistent with organization policies. When determining if certain information should beincluded within a heath-care record, applicable facility policy should be consulted.

Providing Quality Improvement and Risk Management

The client information contained in the health-care record is often a tool used withinquality improvement processes to evaluate services provided and outcomes achieved. Infact, the Canadian Council of Health Services Accreditation (CCHSA) sets standards forclient documentation, which must be met by facilities as part of their accreditationprocess. Comprehensive, accurate documentation provides a sound basis for appropriatemeasurement of the quality of care and facilitates the evaluation of the clients progresstoward preferred outcomes.

A risk-management program is a system to identify, assess and reduce risks to clients,visitors, staff and organizational assets. Good risk-management practice requires cleardocumentation, as health-care records are used for audits and ongoing risk managementanalysis (CRNNS, 2005). The nurses notes are risk-management and quality assurancetools for the employer and the individual nurse (Potter et al., 2006, p.124). Qualitydocumentation is ultimately good risk management for the client receiving care, for thestaff providing the care, and for the organization.

Facilitating Evidence-Based PracticeEvidence-based practice is supported and informed by research findings, as well as by thedepth and breadth of knowledge and experience of registered nurses. The health-carerecord can be an important source of data for nursing and health research and, for thispurpose, accurate and thorough documentation is essential. The documentation by the RNprovides a rich source of information related to nursing interventions and evaluation of client outcomes.


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P ART 2: GUIDELINES FOR DOCUMENTATION The following guidelines provide expectations and suggestions to assist RNs in achievingcomplete and accurate documentation of client care within any setting. They areorganized according to twelve topic areas commonly seen in published material regardingnursing documentation.

1. Objective/Factual DocumentationRegistered nurses must document accurately, completely, and objectively including anyerrors that occurred. An objective description is the result of direct observation andmeasurement. This means it should contain descriptive, objective information about whatthe registered nurse sees, hears, feels and smells. Registered nurses document relevantinformation related to client care but do not record opinions or assumptions. If somethingis not documented, it could be challenged or assumed that it was not done.

It is important that RNs document all information thoroughly, including what was doneand what was observed. For example, if a client was suctioned, the documentation wouldinclude why the client needed suctioning, what the outcome was, and the clientsresponse to suctioning. Registered nurses must record clearly, legibly and accurately anduse appropriate terminology. Use a consistent format that follows documentation policiesand procedures, as well as forms that are specific to each practice setting. Take credit forcare given and sign completely using first initial, full legal surname and designation. Insome practice settings policies may allow the use of initials, but only if they can beuniquely linked to an individual care provider.

Correct spelling and the use of exact measurements ensures that a health-care record isaccurate and demonstrates a level of competency and attention to detail on the part of theRN. Because health-care records reflect accountability for the care provided, registered

nurses should document their own observations and actions only .

2. TimelinessDocumentation is enhanced when client information is entered frequently into the clienthealth-care record (Keatings & Smith, 2000). Contemporaneous documentation, definedas the completion of the health-care record notes as close to the time of care as possible,enhances the credibility and accuracy of health-care records. Documentation of anintervention should never be completed before it takes place .

Documentation in chronological succession assists in revealing a change pattern in aclients health status. Information must be entered on the health-care record even if it isout of chronological order (Phillips, as cited in CRNNS, 2005). In the practice settingpolicies will guide the RN in how late entries are to be documented.

The frequency of documentation and amount of detail documented are dictated by anumber of factors including:

facility/agency policies and procedures the complexity of the health problems the degree to which the clients condition puts them at risk the degree of risk involved in the treatment or care


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While agency policies regarding documentation should be followed to maintain areasonable, prudent standard of documentation, recording of nursing care providedshould be more comprehensive, in depth and frequent if the client is very ill, has unstablehealth-care needs and unpredictable outcomes (CNPS, 2005). Graphically, this is shownas follows:

Frequency ofDocumentation

Variability

Complexity

Acuity

HighMediumLow

Frequency ofDocumentation

Variability

Complexity

Acuity

HighMediumLow

(CRNBC, 2003)

3. Use of SpaceDocumentation must not have empty lines or spaces, and the time when assessments andinterventions were completed must be noted. On forms or flow sheets every requiredspace should be filled. Not applicable or N/A should be noted rather than leaving aspace blank (Baker, 2000).

4. Use of AbbreviationsRegistered nurses need to know what, if any, abbreviations are acceptable in their agency.

Many organizations are currently developing policies that are aimed at reducing thenumber of common but preventable sources of errors. These policies are related toapproved or prohibited abbreviations, or are policies requiring that no abbreviations beused in a practice setting. The Institute for Safe Medication Practices (ISMP)has developed a list of error-prone abbreviations (ISMP, 2006).

5. Follow-upDocument any follow-up of assessments, observations or interventions that have beendone, including whether a physician or other care provider has been notified regardingthe client. Failed attempts to reach a physician or other care provider, the follow-upaction taken, and the clients response to interventions should be documented on the

clients health-care record.6. Correcting ErrorsTo correct an error in a paper-based health-care records system, one method that can beused to appropriately make corrections is the SLIDE rule (Baker, 2000). The SLIDE ruleis completed as follows: cross through the word(s) with a single line, and insert yourinitials, along with the date and time the correction is made; then enter the correctinformation/ explanation. Some agencies require that the correction is highlighted byusing an arrow or asterisk. Check the agency/facility policy for the accepted means of correcting errors, as some require that words such as health-care recording or


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documentation error, error, mistaken entry and void are included with yourinitials.

7. Recording Medication AdministrationDocument the administration of medications immediately after its administration. Thisprevents errors such as another RN administering medication when the first dose was notrecorded. The document Medication Administration: Guidelines for Registered Nurses(CARNA, 2005) outlines important aspects of documentation of medicationadministration. The documentation of medications administered by others is not

acceptable, and RNs should only record medications they have administered themselves. The practice setting policy should be explicit if exceptions are permitted,under what circumstances, and the process to be followed.

The RN should also document in the health-care record additional pertinent informationrelated to the process of administering medications (i.e., self-administration, clientquestions, client refusal of medication), related interventions (i.e., client education,communication with a prescriber) and outcomes of care (i.e., therapeutic drug response,side effects). Registered nurses must also comply with relevant documentationrequirements arising from legislation such as the Controlled Drugs and Substances Act ,as well as practice setting policies.

8. Recording Assistance with CareIn most circumstances, when a RN assists another RN in providing care (e.g., whenassisting another RN to ambulate a patient or insert an IV), the RN providing caredocuments the actions and the clients responses and notes that another care providerassisted. It is not required to name the person who assisted. In certain circumstances, as ina critical incident such as a fall, it is important to record the names of those individualsassisting.

9. Designated Recorder in Emergency Situations

In some emergency situations (e.g., during a cardiac arrest), documentation may be doneby a designated recorder. When acting as a designated recorder, the recorder identifiesthe persons involved and the care they provided. The practice setting policies need toprovide guidance and support for how a designated recorder should document andidentify the forms that are to be used.

10. Clarification of OrdersIf an order is poorly written, never guess or rely on group consensus to interpret thatorder. Always call the writer for clarification. There is a high risk for error and potentialfor an unsafe event to occur. A written record of every telephone call should bemaintained, whether it is with another care provider for clarification of orders, or with aclient following discharge from your facility or unit.

11. Recording a Telephone Conversation with a ClientWhen advice is given by telephone, the RN is relying on the clients own assessment of the situation. The RN does not have the benefit of examination and objective findings.The health-care record should include the date (including year) and time of the call, thenature of the call, the response by the RN, and the follow-up recommendations (Baker,2000).


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12. Interactions with other Health-care ProfessionalsIt is the RNs responsibility when developing care plans, documenting on flow sheets,completing narrative or computerized documentation, or participating in team or familyconferences, to document in the health-care record the outcomes or agreed upon plans of action and the names of the people involved. All health-care professionals are responsiblefor documenting the care they provide or the actions taken. The system used shouldrecord all interactions with members of the health-care team, including clarification of orders, failed attempts to reach other team members, and the follow up action taken.These interactions may involve different formats such as person-to-person, telephone,video-conferencing or other electronic means, and the documentation may use manydifferent tools and forms.

13. Client EducationDocumentation of educational interventions requires knowledge and skills that arecomplex and comprehensive. Registered nurses perform, on a daily basis, a broad scopeand depth of client education. Inadequate or incomplete documentation of clienteducation impedes communication among health-care providers about what has beentaught and diminishes the aspect of this component of care provided by the registerednurse.

When documenting and evaluating client education, it is important to define the extent of the clients understanding (London, as cited in Bastable, 2003). For example, write:Teaching was done related to infection. Client accurately described the signs andsymptoms of infection and reported accurately that if any of these develop, he would callhis primary care provider.

The RN needs to consider the following when documenting client education: Document each formal (planned education) as well as informal (unplanned)

teaching activity. Written education entries should include:

o a brief description of the material taughto the method(s) used for teaching (e.g., written, visual, verbal, auditory, and

instructional aides used)o the involvement of and the interaction between client and family in the

teaching/learning process, and evaluation of the teaching objectives withvalidation of client comprehension and learning

o timed and signed entry Incorporate follow-up education requirements.

14. Documenting an Incident in the Health-care RecordWhen an incident occurs, pertinent data should be documented on the health-care recordsof the client(s) involved in the incident. However, the names of other clients should notbe recorded in anothers health-care record. These names should be documented on anincident/occurrence report. The purposes of a health-care record and anincident/occurrence report differ. The client health-care record is a record of eventsdirectly related to the client. Do not document refer to incident/occurrence report in

the client health-care record. The policy of the practice setting should clearly describethe process of completing an incident/occurrence report.


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An incident report provides a description of an unexpected or unusual event, for example,a client fall, medication error or harm to clients, staff or visitors. Careful documentationof incidents is important for continuous quality improvement, learning from mistakes andmanaging risk, and in case of a complaint or legal action. The following suggestionsprovide guidance on how to complete documentation regarding an incident:

Be concise, accurate and objective. Record what was seen, and describe the care provided, who else was involved and

the clients (persons) condition. Do not try to guess or explain what happened (e.g., the RN should record that side

rails were not in place, but should not write that this was the reason the client fellout of bed).

Record the actions taken by other health-care providers at the time. Do not blame individuals in the documentation. Always record the full facts.

Discuss with the manager and other team members what would be classified as a criticalincident and what should be documented in the health-care record and on an incidentreport. The RN must take time to plan what they will enter into the health-care recordprior to the actual entry. This can help prevent the recording of opinion and the drawingof conclusions that should be avoided in the health-care record.


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P ART 3: DOCUMENTATION S YSTEMS AND METHODS Multiple documentation systems have emerged in recent years in response to changes inhealth-care delivery, and advanced technology has affected the expectations fordocumentation 2. Regardless of the documentation system used, meticulous and accuratedocumentation is necessary to meet the obligations of registered nursing practice whileminimizing legal involvement due to inaccurate or incomplete documentation.

E-health RecordsThere is no doubt that the computerization of the health-care record has many benefits.The same principles apply whether documentation is completed in the paper health-carerecord or electronically. Online documentation is defined as a technology that automatesthe capture of clinical care data. In the nursing realm, this can include assessment data,clinical findings, and nursing plans of care, nursing interventions (along with results),patients progress toward goals, critical pathways, medication administration, risk assessments, discharge planning, patient education and more (Kirkley & Rewick, 2003,p.647). The practice setting must have clear policies and guidelines to address issuesrelated to electronic documentation.

E-health Record SecurityElectronic documentation systems require security features that protect clientconfidentiality and that prevent others from modifying documentation entries. Oncedocumentation is completed, the program should lock entries so that they become readonly information.

The practice setting policies should reference that staff should only have access to health-care records of clients in their specific area of practice. Select staff may be givenauthority to access all health-care records.

To heighten security of passwords, they should be required to be changed at specificintervals of time. The level of access to the e-health record is connected to the username.

The RN should use only his or her own password or access card when gaining access to the e-health record. This ensures that the computer log will accurately reflect that a particular RN made the entry.

When a practice setting has two systems for documentation (paper and electronic)continuity of care must be maintained. E-health records must identify when paper-basedhealth-care records are also being used, and in the event that a paper health-care record isused during an electronic system failure, the electronic health-care record must direct thereader to the paper health-care record. The care provider must sign documentation in ane-health record. Electronic signatures are valid, provided that they are used todemonstrate accountability and are accessible only to the person identified by thatsignature (CNO, 2004).

Incorrect entries must be corrected, indicating who made the correction and when. TheRN needs to know how to correct documentation errors on the e-health record according

2 See Appendix A for table outlining examples of documentation methods, systems and settings.


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to the policies of the practice setting. As with any documentation method, data that havebeen part of the health-care record are not deleted.

For e-health record changes or additions, the RN should refer to their employers policyand follow the process detailed in such policies (CNO, 2004). Making any entry into thehealth-care record must be voluntary. Late entries should be clearly marked as a lateentry. Any alterations, corrections or deletions to the e-health record should be carefullydocumented, dated (including the hour) and properly signed by the RN who is makingadditions to the file. As with a paper file, an alteration to the documentation of another

care practitioner is not permitted.

Methods of DocumentationEfficient documentation methods provide solutions to what is appropriate in a particularcare facility or organization. The systems described below are more fully outlined inAppendix A.

NarrativeNarrative documentation is the traditional method for recording nursing care provided. Itis a story-like format to document information specific to client conditions and nursingcare. Data are recorded in the progress notes without an organizing framework. It oftenrequires the reader to sort through information to locate the data required.

Problem-Orientated Medical Record (POMR)The foundation of this method is a single list of client problems generated by members of the health-care team. The nursing process forms the basis for the POMR method of documenting client problems. Potter et al. (2006) listed the advantages of this method of documenting as follows:

gives emphasis to clients perceptions of their problems requires continuous evaluation and revision of the care plan provides greater continuity of care among health-care team members enhances effective communication among health-care team members increases efficiency in gathering data provides easy-to-read information in chronological order reinforces use of the nursing process

The chronological problem number is not repeated within the same hospitalization. Whenthe problem is resolved, the list is modified by signing a space or check off area next tothe listing. The date that the problem was resolved is noted next to the signature. There isusually another form for narrative progress notes (Meiner, 1999).

SOAP/IEROne of the most prominent features of this problem-orientated method of documentationis the structured way in which narrative progress notes are written by all health-care teammembers, using the SOAP, SOAPIE or SOAPIER format.

Subjective the clients observationsO bjective the care providers observations and testsAssessment the care providers understanding of the problemP lans goals, action, advice


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Intervention when an intervention was identified and changed to meetclients needs

E valuation how outcomes of care are evaluatedR evision when changes to the original problem come from revised

interventions, outcomes of care or time lines this is used todenote changes (Meiner, S., 1999).

PIE

The PIE notes are numbered or labeled according to the clients problems. Resolvedproblems are dropped from daily documentation after the RNs review. Continuingproblems are documented daily (Potter et al., 2006).

P roblem Intervention E valuation

Focus Charting (sometimes referred to as DAR)This method of documentation consists of notes that include data, both subjective andobjective; action or nursing interventions; and r esponse of the client. One distinction of focus documentation is its movement away from documenting only problems. Instead,the notes are structured according to client concerns:

a sign or symptom a condition a nursing diagnosis a behavior a significant event a change in a clients condition

Documentation is written in accordance with the nursing process. Registered nurses areencouraged to broaden their thinking to include any client concerns, not just problemareas, and the critical thinking process is utilized. Focus documentation is easilyunderstood by caregivers and is adaptable to most health-care settings. This approachhelps promote effective documentation (Lampe, as quoted in Potter et al., 2006).

Charting by Exception (CBE)This system of health-care recording assessments, interventions, and responses wasdeveloped to eliminate redundancy and to organize information in a manner that wouldreduce errors in documentation. When used following a thorough orientation to theguidelines and protocols established for nursing assessment and intervention, CBE can:

save time reduce repetition of documentation

provide immediate identification of significant changes in a clients condition

However, in the presence of unclear nursing guidelines or lacking other flow sheets thatare needed for recording other care or treatments, CBE can be more prone to legalinterpretation of a breach in standards in nursing care. If standard care is given usingCBE for documentation, then notations are not needed. A check mark and signature is theonly identification that the standard of care was met . The exceptions to the norm must berecorded. A RN utilizing this method of documentation must be consistent in


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REFERENCES

Baker, S. K. (2000). Minimizing litigation risk: Documentation strategies in theoccupational health setting. AAOHN Journal, 48 (2), 100-105.

Bastable, S. B. (2003). Registered nurse as educator: Principles of teaching and learning for nursing practice. Sudbury, MA: Jones and Bartlett Publishers.

Canadian Nurses Association. (2002). Code of ethics for registered nurses . Ottawa, ON:Author.

Canadian Nurses Protective Society. (1992). Quality documentation: Your best defence .Ottawa, ON: Author.

College and Association of Registered Nurses of Alberta (2003). Nursing practicestandards . Edmonton, AB: Author.

College and Association of Registered Nurses of Alberta. (2005). Medicationadministration: Guidelines for registered nurses. Edmonton, AB: Author

College of Registered Nurses of British Columbia. (2003). Nursing Documentation.Vancouver, BC: Author.

College of Registered Nurses of Ontario. (2004). Practice standard: Documentation .Toronto, ON: Author.

College of Registered Nurses of Nova Scotia. (2005). Documentation guidelines for registered nurses . Halifax, NS: Author.

Grant, A. E. & Ashman, A. A. (1997). A registered nurses practical guide to the law .Aurora, ON: Canada Law Book.

Institute for Safe Medication Practices. (2006). List of error-prone abbreviations,symbols, and dose designations. Retrieved August 31, 2006, fromhttp://www.ismp.org/Tools/errorproneabbreviations.pdf

Keatings, M. & Smith, O. B. (2000). Ethical & legal issues in Canadian nursing (2nd ed.). Toronto, ON: Harcourt Canada.

Kirkley, D. & Rewick, D. (2003). Evaluating clinical information systems. Journal of Nursing Administration, 33 (12), 643-651.

Mastering documentation (2nd ed.). (1999). Springhouse, PA: Springhouse.

Meiner, S. E. (Ed.). (1999). Nursing documentation: Legal focus across practice settings .Thousand Oaks, CA: Sage Publications.

Potter, P. A., Perry, A. G., Ross-Kerr, J. C., & Wood, M. J. (Eds.). (2006). Canadian fundamentals of nursing (3 rd ed.). Toronto, ON: Harcourt Canada.


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APPENDIX B

Legislation - Nursing DocumentationThe following legislation has an effect on nursing documentation and was in force at thetime of printing. The list is not exhaustive.

Federal Access to Information Act (http://laws.justice.gc.ca/en/A-1/218072.html )

Controlled Drugs and Substances Act (http://laws.justice.gc.ca/en/C-38.8/229593.html )

Personal Information Protection and Electronic Documents Act (http://laws.justice.gc.ca/en/P-8.6/258031.html )

Privacy Act (http://laws.justice.gc.ca/en/P-21/255104.html )

Provincial Health Information Act (http://www.qp.gov.ab.ca/Documents/acts/H05.CFM )

Freedom of Information and Protection of Privacy Act (http://foip.gov.ab.ca/legislation/act/index.cfm )

Mental Health Act (http://www.qp.gov.ab.ca/Documents/acts/M13.CFM )

Occupational Health and Safety Act (http://www.qp.gov.ab.ca/documents/acts/O02.cfm )

Health Professions Act (http://www.qp.gov.ab.ca/Documents/acts/H07.CFM )

Personal Information Protection Act (http://www.pipa.gov.ab.ca/index.cfm?page=legislation/act/index.html )

For information on where to obtain copies of current federal legislation, call theGovernment of Canada Inquiry Centre at 1-800-O Canada or visit the Department of Justice website at http://laws.justice.gc.ca .

For information on where to obtain copies of current provincial legislation, call theQueens Printer at 780 427-4952 (toll free dial 310-0000 first and then the number) orvisit the Queens Printer website at www.qp.gov.ab.ca/ .

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