Standards of Psychiatric Mental

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STANDARDS OF PSYCHIATRIC MENTAL

HEALTH NURSING PRACTICE

Standards Of Practice

Standard 1. ASSESSMENT

The psychiatric mental health registered nurse collects comprehensive health data

that is pertinent the patients health or situation.

Rationale

The psychiatric mental health registered nurse uses linguistically and culturally effective

communication skills, interviewing, behavioral observation, record review and collection

of collateral information to make sound clinical assessments.

Measurement Criteria

The Psychiatric-Mental Health Registered Nurse:

Collects data in a systematic and ongoing process.

Involves the patient, family, other healthcare providers, and environment, as appropriate, in

holistic data collection.

Demonstrates effective clinical interviewing skills that facilitate development of a therapeutic

alliance.

Prioritizes data collection activities based on the patients immediate condition or anticipated

needs of the patient or situation. The data may include but is not limited to the patients:

Central complaint, focus or concern and symptoms of major psychiatric disorders.

History and presentation regarding suicidal, violent, and self-mutilating behaviors

to assess level of risk.

History of reliability with regard to patients verbal agreement to seek professional assistance

prior to engaging in behaviors dangerous to self or others.


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Pertinent family history of psychiatric disorders, substance abuse and othermental health

issues.

Evidence ofabuse or neglect.

Stressors, contributing factors and coping strategies.

Scope & Standards Draft Revision 2006

1. Demographic profile and history of health patterns, illnesses and past treatments and level of

adherence and effectiveness.

2. Actual or potential barriers to adherence to recommended or prescribed treatment.

3. Health beliefs and practices.

4. Religious and spiritual beliefs and practices.

5. Cultural, racial and ethnic identity and practices.

6. Physical, developmental, cognitive, mental status, emotional health concerns and

neurological assessment.

7. Daily activities, personal hygiene, occupational functioning, functional health status and

social roles, including work, sleep and sexual functioning.

8. Economic, political, legal, and environmental factors affecting health.

9. Significant support systems and community resources including what has been available and

underutilized.

10. Knowledge, satisfaction, and motivation to change, related to health.

11. Strengths and competencies that can be used to promote health.

12.Current and past medications, both prescribed and over-the-counter inclusive of herbs,

alternative medications, vitamins, or nutritional supplements.

13. Medication interactions and history of side effects and past efficacy.


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14. History and patterns of alcohol and substance abuse including type, amount, most recent

use and withdrawal symptoms.

15. Complementary therapies used to treat health and mental illness and outcomes.

16. Uses appropriate evidence-based assessment techniques and instruments in collecting

pertinent data.

17. Uses analytical modes and problem-solving techniques.

18. Ensures that appropriate consents, as determined by regulations and policies, are obtained

to protect patient confidentiality and support the patients rights in the process of data

gathering.

19.Synthesizes available data, information, and knowledge relevant to the situation to identify

patterns and variances.

20.Uses therapeutic principles to understand and interpret the patients emotion, thoughts and

behaviors.

21.Documents relevant data in a retrievable format.

1 Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice

NurseThe APRN-PMH:

Employs evidence-based clinical practice guidelines to guide screening and diagnostic

activities as available and appropriate. Performs physical and comprehensive mental health

assessment. Initiates and interprets diagnostic tests and procedures relevant to the patients

current status. Conducts a multigenerational family assessment, including medical and

psychiatric history. Assesses the interface among the individual, family, community, and social

systems and their relationship to mental health functioning.

Standard 2. DIAGNOSIS

The psychiatric-mental health registered nurse analyzes the assessment data in

determining diagnoses or problems including level of risk.

Rationale


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Through comprehensive and focused assessment and data analysis the psychiatric mental

health registered nurse identifies patient needs related to actual or potential psychiatric

disorders, mental health problems, and potential co-morbid physical illnesses.


The psychiatric mental health registered nurse:

Derives the diagnosis or problems from the assessment data, Identifies actual or potential risks

to the patients health and safety and/or barriers to mental and physical health which may

include but is not limited to interpersonal, systematic, or environmental circumstances.

Develops diagnoses or problem statements that conform, or are congruent with, available and

accepted classifications systems. Validates the diagnosis or problems with the patient,

significant others and other health care clinicians. Documents diagnoses or problems in a

manner that facilitates the determination of the expected outcomes and plan.

Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice

Registered NurseThe APRN-PMH:

Systematically compares and contrasts clinical findings with normal and abnormal variations

and developmental events in formulating a differential diagnosis. Develops a differential

diagnosis derived from the collection and synthesis of assessment data, and applies

standardized taxonomy systems to the diagnosis of mental health problems and psychiatric

disorders utilizing current DSM & ICD Taxonomy. Utilizes complex data and information

obtained during interview, examination and diagnostic procedures in identifying diagnosis.

Documents the diagnosis. Identifies long-term effects of psychiatric disorders on mental,

physical and socialhealth. Evaluates the health impact of life stressors, traumatic events and

situational crises within the context of the family cycle. Evaluates the impact of the course of

psychiatric disorders and mental health problems on quality of life and functional status.

Assists staff in developing and maintaining competency in the diagnostic process.


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Standard 3. OUTCOMES IDENTIFICATION

The psychiatric mental health registered nurse identifies expected outcomes for a plan

individualized to the patient or to the situation.

Rationale

Psychiatric mental health registered nurses provide nursing care to influence positive. patient

outcomes including the achievement of individualized mental and physical health goals.

1Measurement Criteria

The psychiatric mental health registered nurse: Derives culturally appropriate expected

outcomes from the diagnosis. Involves the patient, family, and other healthcare providers in

formulating expected outcomes when possible and appropriate. Considers associated risks,

benefits, costs, current scientific evidence, and clinical expertise when formulating expected

outcomes. Defines expected outcomes in terms of the patient, patient values, ethical

considerations, environment or situation with such consideration as associated risks,benefits

and costs, and current scientific evidence.Develops expected outcomes that provide direction

for continuity of care. Documents expected outcomes as measurable goals. Includes a time

estimate for attainment of expected outcomes.

Modifies expected outcomes based on changes in the status of the patient or evaluation of the

situation.



Identifies expected outcomes that incorporate scientific evidence and are achievable through

implementation of evidence-based practices.

Identifies expected outcomes that incorporate cost and clinical effectiveness, patient

satisfaction, and continuity and consistency among providers.

Supports the use of clinical guidelines linked to positive patient outcomes.


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Standard 4. PLANNING

The psychiatric mental health registered nurse develops a plan that prescribesstrategies

and alternatives to attain expected outcomes.

1 Rationale

2 A plan of care is used to systematically guide therapeutic interventions and document

progress.



Develops the plan in collaboration with the patient, family, and other health care providers

when appropriate.

Prioritizes elements of the plan based on the assessment of the patients level of risk for

potential harm to self or others and safety needs.

Includes strategies within the plan that address each of the identified diagnoses or issues, which

may include strategies for promotion and restoration of health and prevention of illness, injury,

and disease.

Assists patients in securing treatment or services in the least restrictive environment.

Includes an implementation pathway or timeline within the plan.

Provides for continuity within the plan.

Utilizes the plan to provide direction to other members of the health care team.

Documents the plan using standardized language or recognized terminology.

Defines the plan to reflect current statutes, rules and regulations, and standards.

Develops the plan to reflect the use of available research evidence.

Considers the economic impact of the plan.

Modifies the plan based on ongoing assessment of the patients response and other outcome

indicators.


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1 Additional Measurement Criteria for the Psychiatric Mental Health AdvancedPractice


Within the plan, identifies assessment, diagnostic strategies, and therapeutic interventions to

address mental health problems and psychiatric disorders that reflect current evidence,

including data, research, literature, and expert clinical knowledge.

Plans care to minimize the development of complications and promote function and quality of

life using treatment modalities such as, but not limited to, behavioral therapies, psychotherapy

and psychopharmacology.

Selects or designs strategies to meet the multifaceted needs of complex patients.

Includes synthesis of patients values and beliefs regarding nursing and medical therapies

within the plan.

Standard 5. IMPLEMENTATION

The psychiatric mental health registered nurse implements the identified plan.



Implements the plan in a safe and timely manner.

Documents implementation and any modifications, including changes or omissions of the

identified plan.

Utilizes evidence based interventions and treatments specific to the diagnosis or problem.

Utilizes community resources and systems to implement the plan.

Collaborates with nursing colleagues and others to implement the plan.

Manages psychiatric emergencies by determining the level of risk and initiating and

coordinating effective emergency care.


Registered Nurse.The APRN-PMH:


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Facilitates utilization of systems and community resources to implement the plan. Supports

collaboration with nursing colleagues and other disciplines to implement the plan. Incorporates

new knowledge and strategies to initiate change in nursing care practices if desired outcomes

are not achieved. Implements the plan using principles and concepts of project or systems

management.

Standard 5 A. COORDINATION OF CARE

The psychiatric mental health registered nurse coordinates care delivery.



Coordinates implementation of the plan.

Documents the coordination of care.

Additional Measurement Criteria for Psychiatric Mental Health Advanced Practice


Provides leadership in the coordination of multidisciplinary health care for integrated delivery

of patient care services.

Synthesizes data and information to prescribe necessary system and community support

measures, including environmental modifications.

Coordinates system and community resources that enhance delivery of care across continuums.

Assists patients in getting financial assistance as needed to maintain appropriate care.

Standard 5 B. HEALTH TEACHING AND HEALTH PROMOTION

The psychiatric mental health registered nurse employs strategies to promote health and

a safe environment.

Rationale

The psychiatric mental health registered nurse, through health teaching, promotes the patients

personal and social integration and assists the patient in achieving satisfying, productive, and

health patterns of living.


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The psychiatric mental health registered nurse

Uses health promotion and health teaching methods appropriate to the situation, patients

developmental level, learning needs, readiness, ability to learn, language preference and

culture.

Provides health teaching related to the patients needs and situation that may include, but is not

limited to, mental health problems and psychiatric disorders, treatment regimen, coping skills,

relapse prevention, self-care activities, resources, conflict management, problem-solving skills,

stress management and relaxation techniques, a crisis management. Integrates current

knowledge and research regarding psychotherapeutic educational strategies and content.

Engages consumer alliances and advocacy groups, as appropriate, in health teaching and health

promotion activities. Identifies community resources to assist consumers in using prevention

and mental health care services appropriately. Seeks opportunities for feedback and evaluation

of the effectiveness of strategies utilized. Provides anticipatory guidance to individuals and

families to promote mental health and to prevent or reduce the risk of psychiatric disorders.

1 Additional Measurement Criteria for the Psychiatric Mental Health AdvancedPractice

Registered Nurse.The APRN-PMH:

Educates patients and significant others about intended effects and potential adverse effects of

treatment options.

Provides education to individuals, families, and groups to promote knowledge, understanding

and effective management of overall health maintenance, mental health problems and

psychiatric disorders.

Uses knowledge of health beliefs, practices, evidence-based findings, and epidemiological

principles, along with the social, cultural, and political issues that affect mental health in an

identified community to develop health promotion strategies.

Synthesizes empirical evidence on risk behaviors, learning theories, behavioral change

theories, motivational theories, epidemiology, and other related theories and frameworks when

designing health information and patient education.


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Designs health information and patient education appropriate to the patients developmental

level, learning needs, readiness to learn, and cultural values and beliefs.

Evaluates health information resources, such as the Internet, within the area of practice for

accuracy, readability, and comprehensibility to help patients access quality health information.

Standard 5C. MILIEU THERAPY

The psychiatric mental health registered nurse provides, structures, and maintains asafe

and therapeutic environment in collaboration with the patients, families andother health

care clinicians.

Rationale

The therapeutic environment consists of the physical environment, social structures, and the

philosophy of care and treatment that provides safety at points of crisis and supports the

patients ability to use new adaptive coping strategies and available resources.



Orients the patient and family to the care environment including the physical environment, the

roles of different health care team providers in their care.

1 involved in the treatment and care delivery processes, schedules of events pertinent to their

care and treatment, and expectations regarding behaviors. Orients the patient to their rights and

responsibilities particular to the treatment or care environment.

Conducts ongoing assessments of the patient in relationship to the environment to guide

nursing interventions in maintaining a safe environment and patient safety.

Selects specific activities that meet the patients physical and mental health needs for

meaningful participation in the milieu and promoting personal growth.

Ensures that the patient is treated in the least restrictive environment necessary to maintain the

safety of the patient and others.

Informs the patient in a culturally competent manner about the need for the limits and the

conditions necessary to remove the restrictions.


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Provides the patient with the opportunity to discuss their illness experience with The

psychiatric mental health nurse to promote support, validation and prevention of complications.

Standard 5 D. PHARMACOLOGICAL, BIOLOGICAL AND COMPLEMENTARY

INTERVENTIONS

The psychiatric-mental registered nurse uses knowledge of pharmacological, biological

and complementary interventions and applies clinical skills to restore thepatients health

and prevent further disability.



Applies current research findings to guide nursing actions related to pharmacology, other

biological therapies, and complementary therapies.

Assesses patients response to biological interventions based on current knowledge of

pharmacological agents intended actions, interactive effects, potential untoward effects and

therapeutic doses.

Includes health teaching for medication management to support patients in managing their own

medications, and adherence to prescribed regimen.

Educates on information about mechanism of action, intended effects, potential adverse effects

of the proposed prescription, ways to cope with transitional side effects and other treatment

options, including no treatment.

Directs interventions toward alleviating untoward effects of biological interventions.

Communicates observations about the patients response to biological interventions are to

other health clinicians.

Standard 5E. PRESCRIPTIVE AUTHORITY AND TREATMENT The APRN-PMH

prescribes or recommends, pharmacological agents for patients with mental health

problems and psychiatric disorders based on individualcharacteristics, such as culture,

ethnicity, gender, religious beliefs, age and physicalhealth problems.


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Conducts a thorough assessment of past medical trials, side effects, efficacy and patient

preference. Prescribes or recommends pharmacological agents based on research evidence and

knowledge of psychopathology, neurobiology, physiology, expected therapeutic actions,

anticipated side effects and courses of action. Prescibes or recommends psychotropic and

related medications based on clinical indicators of patient status. Assesses a reasoned balance

of risk and benefits, including results of diagnostic and lab tests as appropriate, to treat

symptoms of psychiatric disorders and improve functional status.

Provides health teaching about mechanism of action, intended effects, potential adverse effects

of the proposed prescription, ways to cope with transitional side effects and other treatment

options, including no treatment.

Educates and assists the patient in selecting the appropriate use of complementary and

alternative therapies. Evaluates therapeutic and potential adverse effects of pharmacological

and non pharmacological treatments. Evaluates pharmacological outcomes by utilizing standard

symptom measurements and patient report to determine efficacy.

Adjusts medications based on continual monitoring in collaboration with patient.

Standard 5F. PSYCHOTHERAPY

The Psychiatric Mental Health Advanced Practice Registered Nurse conducts individual,

couples, group, and/or family psychotherapy using evidence-based psychotherapeutic

frameworks, interpersonal transactions and nurse-patienttherapeutic relationship.


The APRN-PMH:

Uses knowledge of personality theory, growth and development, psychology, neurobiology,

psychopathology, social systems small-group and family dynamics, stress and adaptation, and

theories and best available research evidence to select therapeutic methods based on the

patients needs.

Structures the therapeutic contract to include, but not limited to:

Purpose, goals, and expected outcomes


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Time, place and frequency of therapy

Participants involved in therapy

Confidentiality and appropriate written release of information

Availability and means of contacting therapist

Responsibilities of both patient and therapist

Fees and payment schedule

Cancellations/alteration in schedule policy

Utilizes interventions that promote mutual trust to build a therapeutic treatment alliance.Empowers patients to be active participants in treatment.

Applies therapeutic communication strategies based on theories and research evidence to

reduce emotional distress, facilitate cognitive and behavioral change and foster personal

growth. Uses self-awareness of emotional reactions and behavioral responses to others to

enhance the therapeutic alliance.

Analyzes the impact of duty to report and other advocacy actions on the therapeutic alliance.

Arranges for the provision of care in the therapists absence.

Applies ethical and legal principles to the treatment of patients with mental health problems

and psychiatric disorders.

Makes referrals when it is determined that the patient will benefit from a transition of care or

consultation due to change in clinical condition.

Evaluates effectiveness of interventions is relation to outcomes using standardized methods as

appropriate.

Monitors outcomes of therapy and adjusts plan of care when indicated.

Therapeutically concludes the nurse-patient relationship and transitions the patient to

other levels of care, when appropriate.


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Identifies and maintains professional boundaries to preserve the integrity of thetherapeutic

process.

Standard 5G. CONSULTATION

The psychiatric mental health advanced practice nurse provides consultation to influence

the identified plan, enhance the abilities of other clinicians to provide services for patients

and effect change.


The APRN-PMH:

Synthesizes clinical data, theoretical frameworks, and evidence when providing consultation.Initiates consultation at the request of the consultee.

Establishes a working alliance with the patient or consultee based on mutual respect and role

responsibilities.

Facilitates the effectiveness of a consultation by involving the stakeholders in the decision-

making process.

Communicates consultation recommendations that influence the identified plan, facilitate

understanding by involved stakeholders , enhance the work of others, and effect change.

Clarifies that implementation of system changes or changes to the plan of care remain the

consultees responsibility.

Standard 6. EVALUATION

The psychiatric mental health registered nurse evaluates progress toward attaining

expected outcomes.


The psychiatric mental health registered nurse: Conducts a systematic, ongoing, and

criterion-based evaluation of the outcomes inrelation to the structures and processes prescribed

by the plan and indicated timeline.

Involve the patient, family or significant others, and other health care clinicians in the

evaluation process.


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Documents results of the evaluation.

Evaluates the effectiveness of the planned strategies in relation to patient responses and the

attainment of the expected outcomes.

Uses on going assessment data to revise the diagnoses, outcomes, the plan and the

implementation as needed.

Disseminates the results to the patient and others involved in the care or situation, as

appropriate, in accordance with state and federal laws and regulations.


Nurse: The APRN-PMH:

Evaluates the accuracy of the diagnosis and effectiveness of the interventions in relationship to

thepatients attainment of expected outcomes.

Synthesizes the results of the evaluation analyses to determine the impact of the plan on the

affected patients, families, groups, communities, and institutions.

Uses the results of the evaluation analyses to make or recommend process or structural

changes, including policy, procedure, or protocol documentation, as appropriate Psychiatric

Mental Health NursingScope & Standards Draft Revision 2006

STANDARDS OF PROFESSIONAL PERFORMANCE

Standard 7. QUALITY OF PRACTICE

The psychiatric mental health registered nurse systematically enhances the quality

and effectiveness of nursing practice.


The psychiatric-mental health registered nurse:

Demonstrates quality by documenting the application of the nursing process in a responsible,

accountable, and ethical manner.Uses the results of quality improvement activities to initiate

changes in nursing practice and in the healthcare delivery system.

Uses creativity and innovation in nursing practice to improve care delivery.


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Incorporates new knowledge to initiate changes in nursing practice if desired outcomes are not

achieved.

Obtains and maintains certification in psychiatric mental health nursing.

Participates in quality improvement activities. Such activities may include:

Identifying aspects of practice important for quality monitoring.

Using indicators developed to monitor quality and effectiveness of nursing practice.

Collecting data to monitor quality and effectiveness of nursing practice.

Analyzing quality data to identify opportunities for improving nursing practice.

Formulating recommendations to improve nursing practice or outcomes.

Implementing activities to enhance the quality of nursing practice.

Developing, implementing, and evaluating policies, procedures and/orguidelines to improve the

quality of practice.

Participating on interdisciplinary teams to evaluate clinical care or health services.

Participating in efforts to minimize costs and unnecessary duplication.

Analyzing factors related to safety, satisfaction, effectiveness, and cost/benefit options.

Analyzing organizational systems for barriers

Psychiatric Mental Health Nursing Page 36 OF 49


Implementing processes to remove or decrease barriers within organizational systems.


Nurse.

The APRN-PMH:

Obtains and maintains professional certification if available in the area of expertise.

Designs quality improvement initiatives.


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Implements initiatives to evaluate the need for change.

Evaluates the practice environment and quality of nursing care rendered in relation to existing

evidence, identifying opportunities for the generation and use of research.

Standard 8. EDUCATION

The psychiatric mental health registered nurse attains knowledge and competency that

reflects current nursing practice.



Participates in ongoing educational activities related to appropriate knowledge bases and

professional issues.

Demonstrates a commitment to lifelong learning through self-reflection and inquiry to identify

learning needs.

Seeks experiences that reflect current practice in order to maintain skills and competence in

clinical practice or role performance.

Acquires knowledge and skills appropriate to the specialty area, practice setting,role, or

situation.

Maintains professional records that provide evidence of competency and life long learning.



Seeks experiences and formal and independent learning activities to maintain and

develop clinical and professional skills and knowledge.

Additional Measurement Criteria for the Psychiatric Mental Health Advanced

Practice Nurse:

The APRN- PMH:


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Uses current healthcare research findings and other evidence to expand clinical knowledge,

enhance role performance, and increase knowledge of professional issues.

Standard 9: PROFESSIONAL PRACTICE EVALUATION

The psychiatric mental health registered nurse evaluates his/her own practice in relation

to the professional practice standards and guidelines, relevant statutes, rules, and

regulations.



Demonstrates the application of knowledge of current practice standards, guidelines, statutes,rules, and regulations.

Provides age appropriate care in a culturally and ethnically sensitive manner.

Engages in self-evaluation of practice on a regular basis, identifying areas of strength as well as

areas in which professional development would be beneficial. Obtains informal feedback

regarding ones own practice from patients, peers, professional colleagues, and others.

Participates in systematic peer review as appropriate.

Takes action to achieve goals identified during the evaluation process.

Provides rationale for practice beliefs, decisions, and actions as part of the informal and formal

evaluation processes.




Registered Nurse:

The APRN-PMH:

Engages in a formal process seeking feedback regarding ones own practice from patients,

peers, professional colleagues, and others.

Standard 10. COLLEGIALITY


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The psychiatric mental health registered nurse interacts with and contributes to the

professional development of peers and colleagues.



Shares knowledge and skills with peers and colleagues as evidenced by such activities as

patient care conferences or presentations at formal or informal meetings.

Provides peers with feedback regarding their practice and/or role performance.

Interacts with peers and colleagues to enhance ones own professional nursing practice and/or

role performance.

Maintains compassionate and caring relationships with peers and colleagues.

Contributes to an environment that is conducive to the education of healthcare professionals.

Contributes to a supportive and healthy work environment.

Additional Measurement Criteria for the psychiatric mental health advanced practice

nurse.

The APRN-PMH:

Models expert practice to interdisciplinary team members and healthcare consumers.

Mentors other registered nurses and colleagues as appropriate.

Participates with interdisciplinary teams that contribute to role development and advanced

nursing practice and health care.



Standard 11: COLLABORATION

The psychiatric mental health registered nurse collaborates with patients, family and

others in the conduct of nursing practice.


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Communicates with patient, family, and healthcare providers regarding patient care and the

nurses role in the provision of that care.

Collaborates in creating a documented plan focused on outcomes and decisions related to care

and delivery of services that indicates communication with patients, families, and others.

Partners with others to effect change and generate positive outcomes through knowledge of the

patient or situation.

Documents referrals, including provisions for continuity of care.


Registered Nurse.

The APRN-PMH:

Partners with other disciplines to enhance patient care through interdisciplinary activities, such

as education, consultation, management, technological development, or research opportunities.

Facilitates an interdisciplinary process with other members of the healthcare team.

Documents plan of care communications, rationales for plan of care changes, and collaborative

discussions to improve patient care.

Standard 12: ETHICS

The psychiatric mental health registered nurse integrates ethical provisions in allareas of

practice.






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Uses the Code of Ethics for Nurses with Interpretive Statements (ANA, 2001) to guide practice.

Delivers care in a manner that preserves and protects patient autonomy, dignity and rights.

Maintains patient confidentiality within legal and regulatory parameters.

Serves as a patient advocate assisting patients in developing skills for self advocacy.

Maintains a therapeutic and professional patientnurse relationship with appropriate

professional role boundaries and does not promote or engage in intimate, sexual, or business

relationships with current or former patients.

Monitors and carefully manages self-disclosure therapeutically.

Demonstrates a commitment to practicing self-care, managing stress, and connecting with self

and others.

Contributes to resolving ethical issues of patients, colleagues, or systems as evidenced in such

activities as participating on ethics committees.

Reports illegal, incompetent, or impaired practices.

Additional Measurement Criteria for the Psychiatric Mental Health Advanced

Practice Nurse

The APRN-PMH:

Informs the patient of the risks, benefits, and outcomes of healthcare regimens.

Participates in interdisciplinary teams that address ethical risks, benefits, and outcomes.

Standard 13: RESEARCH

The psychiatric mental health registered nurse integrates research findings intopractice.






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Utilizes the best available evidence, including research findings, to guide practice decisions.

Actively participates in research activities at various levels appropriate to the nurses level of

education and position. Such activities may include:

Identifying clinical problems specific to psychiatric-mental health nursing research (patient

care and nursing practice).

Participating in data collection (surveys, pilot projects, formal studies)

Participating in a formal committee or program.

Sharing research activities and/or findings with peers and others

Conducting research.

Critically analyzing and interpreting research for application to practice.

Using research findings in the development of policies, procedures, and standards of practice in

patient care.

Incorporating research as a basis for learning.


Nurse The APRN-PMH:

Contributes to nursing knowledge by conducting, critically appraising or synthesizing research

that discovers, examines and evaluates knowledge, theories, criteria, and creative approaches to

improve healthcare practice.

Formally disseminates research findings through activities such as presentations,publications,

consultation, and journal clubs.

Demonstrates leadership in promoting a culture that consistently integrates the best available

research evidence into practice.

STANDARD 14. RESOURCE UTILIZATION

The psychiatric mental health registered nurse considers factors related to

safety,effectiveness, cost, and impact on practice in the planning and delivery of nursing

services.


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7Measurement Criteria


Evaluates factors such as safety, effectiveness, availability, cost and benefits, efficiencies, and

impact on practice, when choosing practice options that would result in the same expected

outcome.

Assists the patient and family in identifying and securing appropriate and available services to

address health-related needs.

Assigns or delegates tasks, based on the needs and condition of the patient, potential for harm,

stability of the patients condition, complexity of the task, and predictability of the outcome.

Assists the patient and family in becoming informed consumers about the options, costs, risks,

and benefits of treatment and care.


Nurse: The APRN-PMH:

Utilizes organizational and community resources to formulate multidisciplinary or

interdisciplinary plans of care.

Develops innovative solutions for patient care problems that address effective resource

utilization and maintenance of quality.

Develops evaluation strategies to demonstrate quality, cost effectiveness, cost benefit, and

efficiency factors associated with nursing practice.

STANDARD 15. LEADERSHIP

The psychiatric mental health registered nurse provides leadership in the professional

practice setting and the profession.


The psychiatric-mental health registered nurse: Engages in teamwork as a team player and a

team builder.

Works to create and maintain healthy work environments in local, regional, national, or

international communities.


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Displays the ability to define a clear vision, the associated goals, and a plan to implement and

measure progress.

Demonstrates a commitment to continuous, life long learning for self and others.

Teaches others to succeed by mentoring and other strategies.

Exhibits creativity and flexibility through times of change.

Demonstrates energy, excitement, and a passion for quality work.

Willingly accepts mistakes by self and others thereby creating a culture in which risk-taking is

not only safe, but expected.

Inspires loyalty through valuing of people as the most precious asset in an organization.

Directs the coordination of care across settings and among caregivers, including oversight of

licensed and unlicensed personnel in any assigned or delegated tasks.

Serves in key roles in the work setting by participating on committees, councils, and

administrative teams.

Promotes advancement of the profession through participation in professional organizations.

Additional Measurement Criteria for the Psychiatric Mental health Advanced Practice

Nurse The APRN-PMH:

Utilizes ethical principles to create a system of advocacy for access and parity for mental health

problems, psychiatric disorders, and addiction services.

Influences health policy to reduce the impact of stigma on services for prevention and treatment

of mental health problems and psychiatric disorders.

Works to influence decision-making bodies to improve patient care.

Provides direction to enhance the effectiveness of the healthcare team.

Initiates and revises protocols or guidelines to reflect evidence-based practice, to reflect

accepted changes in care management, or to address emerging problems.

Promotes communication of information and advancement of the profession through writing,

publishing, and presentations for professional or lay audiences.


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Designs innovations to effect change in practice and improve health outcomes.


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DOCUMENTATION

D E F I N I T I O N

Documentation is any written or electronically generated information about a client that

describes the care or service provided to that client. Health records may be paper documents or

electronic documents, such as electronic medical records, faxes, e-mails, audio or video tapes

and images. Through documentation, nurses communicate their observations, decisions, actions

and outcomes of these actions for clients. Documentation is an accurate account of what

occurred and when it occurred. Nurses may document information pertaining to individual

clients or groups of clients.

Individual Clients : When caring for an individual client (which may include the clients

family), the nurses documentation provides a clear picture of the status of the client, the

actions of the nurse, and the client outcomes.

Nursing documentation clearly describes: an assessment of the clients health status, nursing

interventions carried out, and the impact of these interventions on client outcomes; a care plan

or health plan reflecting the needs and goals of the client; needed changes to the care plan;

information reported to a physician or other health care provider and, when appropriate, that

providers response; and advocacy undertaken by the nurse on behalf of the client.

Groups of Clients

When providing service to groups of clients (e.g., therapy groups, public health programs),

service records (or an equivalent) are used to document the service provided and overall

observations pertaining to the group. Similar to documentation for individuals, documentation

for groups reflects the needs assessment, plans, actions taken, and evaluation of the group

outcomes.


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Documentation of services provided to a group of clients describes:

The purpose and goal of the group

The criteria for participation

Intervention activities and group processes and

An evaluation of group outcomes.

N U R S I N G D O C U M E N T A T I O N

Pertinent information about individual clients within the group is documented on individual

client health records, not on the group service record. When charting on an individual client

health record, names of other group members are not identified.

R E A S O N S F O R D O C U M E N T A T I O N

To facilitate communication Through documentation, nurses communicate to other nurses and care providers their

assessments about the status of clients, nursing interventions that are carried out and the

results of these interventions.

Documentation of this information increases the likelihood that the client will receiveconsistent and informed care or service.

Thorough, accurate documentation decreases the potential for miscommunication anderrors. While documentation is most often done by nurses and care providers, there are

situations where the client and family may document observations or care provided in

order to communicate this information with members of the health care team.

To promote good nursing care Documentation encourages nurses to assess client progress and determine which

interventions are effective and which are ineffective, and identify and document

changes to the plan of care as needed.


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Documentation can be a valuable source of data for making decisions about funding andresource management as well as facilitating nursing research, all of which have the

potential to improve the quality of nursing practice and client care.

Individual nurses can use outcome information or information from a critical incident toreflect on their practice and make needed changes based on evidence.

To meet professional and legal standardsDocumentation is a valuable method for demonstrating that, within the nurse-client

relationship, the nurse has applied nursing knowledge, skills and judgment according to

professional standards. The nurses documentation may be used as evidence in legal

proceedings such as lawsuits, coroners inquests, and disciplinary hearings through professional

regulatory bodies. In a court of law, the clients health record serves as the legal record of the

care or service provided. Nursing care and the documentation of that care will be measured

according to the standard of a reasonable and prudent nurse with similar education and

experience in a similar situation.

T O O L S F O R D O C U M E N T A T I O N

There are many tools used for client documentation, including worksheets and kardexes, client

care plans, flowsheets and checklists, care maps, clinical pathways and monitoring strips. These

tools may be written or electronic in format. Regardless of the tool used, pertinent information

specific to an individual client resides within the clients health record.

Worksheets and kardexes

Nurses use worksheets to organize the care they provide, and to manage their time and multiple

priorities.


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Kardexes are used to communicate current orders, upcoming tests or surgeries, special diets or

the use of aids for independent living specific to an individual client (College of Nurses of

Ontario, 2002). If a paper format is used,entries may be erasable as long as the assessment,

nursing interventions carried out and the impact of these interventions on client outcomes are

documented in the permanent health record.


Documentation of the clients care plan, it is kept as part of the permanent record.

Client care plans

Care plans are outlines of care for individual clients and make up part of the permanent health

record. Care plans are written in ink (unless electronic), up-to-date and clearly identify the

needs and wishes of the client.

Flow sheets and checklists

Flow sheets and checklists are used to document routine care and observations that are recorded

on a regular basis (e.g., activities of daily living, vital signs, intake and output). Flow sheets and

checklists are part of the permanent health record, and can be used as evidence in legal

proceedings (College of Nurses of Ontario, 2002). Symbols (e.g., check marks) may be used on

flow sheets or checklists as long as it is clear who performed the assessment or intervention and

the meaning of each of the symbols is identified in agency policy.

Care maps and clinical pathways

Care maps and clinical pathways outline what care will be done and what outcomes are

expected over a specified time frame for a usual client within a case type or grouping. Nurses


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individualize care maps and clinical pathways to meet clients specific needs (e.g., by making

changes to items that are not appropriate). If the status of clients varies from that outlined on

the care map or clinical pathway at a particular time period, the variance is documented,

including the reasons and action plan to address it.

Monitoring strips

Monitoring strips (e.g., cardiac, fetal or thermal monitoring; blood pressure testing) provide

important assessment data and are included as part of the permanent health record.

I N C I D E N T R E P O R T S

Agencies often have policies that require nurses to complete incident reports following unusual

occurrences, such as medication errors or harm to clients, staff or visitors. Regardless of

whether incident reports are used, nurses have a professional obligation to document the actual

care provided to an individual in the clients health record.

Incident reports are administrative risk management tools to track trends and patterns about

groups of clients over time. Incident reports are to be used for quality assurance not punitive

purposes. Incident reports completed in hospital based agencies are protected from disclosure

in legal proceedings in section 51 of the Evidence Act (2001). Therefore, they are retained

separately from the health record and no reference to an incident report is made in the health

record to protect the incident report from subpoena.

British Columbia Health Care Risk Management Society (2002) recommends the following:

Ensure that the facts of the incident are recorded separately from opinions about the cause of

the incident and from any quality assurance follow-up information. Some organizations have a

two-part incident report with follow-up and recommendations separate from the rest of the

report.


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Never promise a patient/family a copy of an incident report or of any report arising out of

quality assurance investigation - section 51 of the Evidence Act prohibits this.


Directives for Documentation

Requirements for documentation and the sharing, retention and disposal of this information are

drawn from several sources: statutory regulations; Standards of Practice; agency policies and

procedures; and legal principles.

S T A T U T O R Y R E G U L A T I O N S

There are no laws in BC stating specifically how and what nurses must document. Agencies

generally develop documentation policies which reflect provincial and federal government

statutes and/or other relevant documents.

The following statutes and documents guide policy in most B.C. agencies:

British Columbia Coroners Act Health Professions Act

Child, Family and Community Service Act Hospital Act

Controlled Drug and Substances Act (Federal) Health Care (Consent) and Facilities Act

Electronic Transactions Act Limitation Act

Evidence Act Medical Practitioners Act

Freedom of Information and Protection of Privacy Act Mental Health Act

Health Act

Other Relevant Documents


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S T A N D A R D S O F P R A C T I C E

Professional Standards for Registered Nurses and Nurse Practitioners

A standard is a desired and achievable level of performance against which actual performance

can be compared.

Each of the six Professional Standards incorporates one of the characteristics of the profession

and provides direction to nurses about documentation.

Examples of How Nurses Meet the CRNBC Professional Standards:

Standard 1: Responsibility and Accountability: Maintains standards of nursing practice and

professional conduct determined by CRNBC and the practice setting.

Examples: Document all relevant data.

Ensure that each entry clearly identifies the nurse.

Be familiar with and use the documentation method used in the agency.

Advocate for agency policies and procedures that are clear and consistent with CRNBC

documentation standards.

Standard 2: Specialized Body of Knowledge: Bases practice on the best evidence and other

sciences and humanities.

Example:

Understand the purpose of and reasons for accurate and effective documentation.

Standard 3: Competent Application of Knowledge: Makes decisions about actual or potential

health problems and strengths, plans and performs interventions, and evaluates outcomes.

Examples: Document client assessments, interventions and the impact of interventions on client

outcomes according to agency policies and the CRNBC Standards of Practice.

Individualize care plans to meet the needs and wishes of individual clients.


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Standard 4: Code of Ethics: Adheres to the ethical standards of the nursing profession.

Examples: Be familiar with agency policies related to confidential information.

Safeguard the security of printed or electronically displayed or stored information.

Dispose of confidential information in a manner that preserves confidentiality (e.g., shredding).

Act as an advocate to protect and promote clients rights to confidentiality and access to

information.

Standard 5: Provision of Service in the Public Interest: Provides nursing services and

collaborates with other members of the health care team in providing health care services.

Examples: Use documentation to share knowledge about clients with other nurses and health

care professionals.Regularly update kardex information and ensure that relevant client care

information is captured in the permanent health record.

Keep the care plan clear, current and useful.

Standard 6: Self-Regulation: Assumes primary responsibility for maintaining competence and

fitness to practice.

Example: Keep current with changes in the documentation method used.

Practice Standard: Documentation

The CRNBC Practice StandardDocumentation sets out requirements related to documentation

and nurses practice. It also provides direction on how to apply the principles in the Standard to

practice.


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A G E N C Y P O L I C I E S A N D P R O C E D U R E S

Most health care agencies have documentation policies. These policies provide direction for

nurses to document the nursing care provided and the process of clinical decision-making in an

accurate and efficient manner. Agency policies include:

Description of the method of documentation; Expectations for the frequency of documentation; Processes for late entry recording; listing of acceptable abbreviations or the name of a reference text in which acceptable

abbreviations are found;

Acceptance and recording of verbal and telephone orders; and Storage, transmittal and retention of client information. Agency policies guide nurses in managing each of these specific situations. In situations

where policy changes are necessary, nurses advocate for the appropriate changes.

L E G A L P R I N C I P L E S

Legal standards for documentation have evolved over time and continue to evolve. Many are

based on Canadian common law court decisions as illustrated in the following examples:

Nurses notes are recognized as documentary evidence.

Case: Ares vs. Venner, 1970

Prior to 1970, nurses notes were not considered legal evidence admissible in court unless the

nurse was called to testify to the truth of the contents. In 1970, a new law was made in the Ares

vs. Venner case when, for the first time, nurses notes were recognized as admissible evidence.

Nurses notes were viewed as a record of the nursing care provided to the client. This case set

out the conditions in which nurses notes are now admissible (Richard,1995): nurses notes


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must be made contemporaneously; nurses notes must be made by someone having personal

knowledge of the matter then being recorded; and nurses notes must be made by someone

under a duty of care to make the entry or record.

Charting by exception can provide admissible evidence.

Cases: Kolesar vs. Jeffries, 1974; Ferguson vs. Hamilton, 1983; Wendon vs. Trikha, 1993

The health record is important both for what is recorded and for what is not recorded. In the

case of Kolesar vs.Jeffries (1974), the nurses notes were introduced as evidence and the

absence of entries permitted the inference that nothing was charted because nothing was

done. However, in a subsequent case, Ferguson vs. Hamilton (1983), the court rejected the

submission that the absence of any nurses entry is an indication of failure in care on the part of

the nurse(s). In this case, the court concluded that the fact that there was nothing in the nurses

notes during a period of time did not necessarily mean nothing was done, provided there was

evidence to the contrary and the usual practice was not to chart (Richard, 1995).

In the case of Wendon vs. Trikha (1993), the court concluded that omissions in documentation

will be interpreted against a nurse unless other credible evidence of nursing care demonstrates

that care was given. It means that if charting by exception is an agency policy, and if evidence

can be given that care was provided and noted according to this method, then this evidence will

be admissible and will provide proof of what was done (Richard, 1995). To meet legal

documentation standards, a system of charting by exception must include such supports such as

agency documentation policies, assessment norms, standards of care, individualized care plans

and flow sheets.


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Documentation Methods

Most methods of documentation fall into one of two categories: documentation by inclusion

and documentation by exception (Coleman, 1997). Documentation by inclusion is done on an

ongoing, regular basis and makes note of all assessment findings, nursing interventions and

client outcomes. Documentation by exception, on the other hand, makes note of negative

findings and is completed when assessment findings, nursing interventions or client outcomes

vary from the established assessment norms or standards of care existing within a particular

agency.

Charting by exception replaces the long held belief of if it was not charted, then it was not

done with a newpremise, all standards have been met with a normal or expected response

unless documented otherwise.

Documentation by exception is only appropriate when assessment norms or standards of care

are explicitly written and available within the agency. Documentation by exception is never

acceptable for medication administration.

The documentation method selected within an agency or practice setting needs to reflect client

care needs and the context of practice. Some agencies may combine elements of different

documentation methods and formats. If an agency decides to change its method or format of

documentation and/or expectations, it is important that this be done within a context of

appropriate planning and includes the involvement and education of nurses.

Regardless of the method used, nurses are responsible and accountable for documenting client

assessments, interventions carried out, and the impact of the interventions on client outcomes.

Clients who are very ill, considered high risk, or have complex health problems generally

require more comprehensive, in-depth and frequent documentation.


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Three common documentation methods - focus charting, SOAP/SOAPIER and narrative

documentation are described in the following sections. Any of these methods may be used to

document on an inclusion or exception basis.

F O C U S C H A R T I N G

With this method of documentation, the nurse identifies a focus based on client concerns or

behaviours determined during the assessment. For example, a focus could reflect:

A current client concern or behaviour, such as decreased urinary output.

A change in a clients condition or behavior, such as disorientation to time, place and person.

A significant event in the clients treatment, such as return from surgery.

In focus charting, the assessment of client status, the interventions carried out and the impact of

the interventions on client outcomes are organized under the headings of data, action and

response.

Data: Subjective and/or objective information that supports the stated focus or describes the

client status at the time of a significant event or intervention.

Action: Completed or planned nursing interventions based on the nurses assessment of the

clients status.

Response: Description of the impact of the interventions on client outcomes.

Flow sheets and checklists are frequently used as an adjunct to document routine and ongoing

assessments and observations such as personal care, vital signs, intake and output, etc.

Information recorded on flow sheets or checklists does not need to be repeated in the progress

notes.


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S O A P / S O A P I E ( R ) C H A R T I N G

SOAP/SOAPIER charting is a problem-oriented approach to documentation whereby the

nurse identifies and lists client problems; documentation then follows according to the

identified problems.

Documentation is generally organized according to the following headings:

S = subjective data (e.g., how does the client feel?)

O = objective data (e.g., results of the physical exam, relevant vital signs)

A = assessment (e.g., what is the clients status?)

P = plan (e.g., does the plan stay the same? is a change needed?)

I = intervention (e.g., what occurred? what did the nurse do?)

E = evaluation (e.g., what is the client outcome following the intervention?)

R = revision (e.g., what changes are needed to the care plan?)

Similar to focus charting, flow sheets and checklists are frequently used as an adjunct to

document routine and ongoing assessments and observations.

N A R R A T I V E C H A R T I N G

Narrative charting is a method in which nursing interventions and the impact of these

interventions on client outcomes are recorded in chronological order covering a specific time

frame. Data is recorded in the progress notes, often without an organizing framework. Narrative

charting may stand alone or it may be complemented by other tools, such as flow sheets and

checklists.

Use of Technology

Technology may be used to support client documentation in a number of ways. If technology is

used, the principles underlying documentation, access, storage, retrieval and transmittal of

information remain the same as for a traditional, paper-based system. These new ways of


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recording, delivering and receiving client information, however, pose significant challenges for

nurses, particularly with respect to confidentiality and security of client information. It is

important that nurses be supported by agencies in resolving these issues through clear policies

and guidelines and ongoing education.

E L E C T R O N I C D O C U M E N T A T I O N

A clients electronic health record is a collection of the personal health information of a single

individual, entered or accepted by health care providers, and stored electronically, under strict

security.

As with traditional or paper-based systems, documentation in electronic health records must be

comprehensive, accurate, timely, and clearly identify who provided what care (College of

Nurses of Ontario, 2002). Entries are made by the provider 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. If corrections are required to the entry after the entry has

been stored, agency policies provide direction as to how this should occur.

Most agencies using electronic documentation have policies to support its use, including

policies for:

Correcting documentation errors or making late entries;

Preventing the deletion of information;

Identifying changes and updates to the record;

Protecting the confidentiality of client information;

Maintaining the security of the system (passwords, virus protection, encryption, firewalls);

Tracking unauthorized access to client information;

Processes for documenting in agencies using a mix of electronic and paper methods;

Backing-up client information; and


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Means of documentation in the event of a system failure.

Guidelines for nurses using electronic health records are as follows:

Never reveal or allow anyone else access to your personal identification number or password as

these are, infact, electronic signatures;

Inform your immediate supervisor if there is suspicion that an assigned personal identification

code is being used by someone else;

Change passwords at frequent and irregular intervals (as per agency policy);

Choose passwords that are not easily deciphered;

Log off when not using the system or when leaving the terminal;

Maintain confidentiality of all information, including all print copies of information;

Shred any discarded print information containing client identification;

Locate printers in secured areas away from public access;

Retrieve printed information immediately;

Protect client information displayed on monitors (e.g., use of screen saver, location of monitor,

use of privacy screens);

Use only systems with secured access to record client information; and

Only access client information which is required to provide nursing care for that client;

accessing client information for purposes other than providing nursing care is a breach of

confidentiality.

F A X T R A N S M I S S I O N

Facsimile (fax) transmission is a convenient and efficient method for communicating

information between health care providers. Protection of client confidentiality is the most

significant risk in fax transmission and special precautions are required when using this form of

technology.


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Guidelines for protecting client confidentiality when using fax technology to transmit

client information are as follows:

Locate fax machines in secured areas away from public access;

Check that the fax numbers and/or fax distribution lists stored in the machine of the sender

are correct prior to dialing;

Carefully check activity reports to confirm successful transmission;

Include cover sheet warnings indicating the information being transmitted is confidential; also

request verification that, in the event of a misdirected fax, it will be confidentially and

immediately destroyed without being read;

Make a reasonable effort to ensure that the fax will be retrieved immediately by the intended

recipient, or will be stored in a secure area until collected;

Shred any discarded faxed information containing client identification; and

Advocate for secure and confidential fax transmittal systems and protocols.

Client information received or sent by fax is a form of client documentation and is stored

electronically or printed

In hard copy and placed in the clients health record. As the fax is an exact copy of original

documentation,

Additional notations may be made on the faxed copy as long as these meet the agency

standards for

Documentation and are appropriately dated and signed. Faxes are part of the clients permanent

record and, if relevant, can be subject to disclosure in legal proceedings. Faxed information is

written with this in mind.

If a physicians order is received by fax, nurses use whatever means necessary to confirm the

authenticity of the order.


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E L E C T R O N I C M A I L

The use of e-mail by health care organizations and health care professionals is becoming more

widespread as a result of its speed, reliability, convenience and low cost. Unfortunately the

factors that make the use of e-mail so advantageous also pose significant confidentiality,

security and legal risks.

E-mail can be likened to sending a postcard. It is not sealed, and may be read by anyone.

Because the security and confidentiality of e-mail cannot be guaranteed, it is not recommended

as a method for transmission of health information. Messages can easily be misdirected to or

intercepted by an unintended recipient. The information can then be read, forwarded and/or

printed. Although messages on a local computer can be deleted, they are never deleted from the

central server routing the message and can, in fact, be retrieved.

Having considered these risks and alternative ways to transmit health information, e-mail may

be the preferred option to meet client needs in some cases.

Guidelines for protecting client confidentiality when using e-mail to transmit client

information are as follows:

Obtain written consent from the client when transferring health information by e-mail;

Check that the e-mail address of the intended recipient(s) is correct prior to sending;

Transmit e-mail using special security software (e.g., encryption, user verification or secure

point-to-point connections);

Ensure transmission and receipt of e-mail is to a unique e-mail address;

Never reveal or allow anyone else access to your password for e-mail;

Include a confidentiality 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;

Never forward an e-mail received about a client without the clients written consent;


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Maintain confidentiality of all information, including that reproduced in hard copy;

Locate printers in secured areas away from public access;

Retrieve printed information immediately; and

Advocate for secure and confidential e-mail systems and protocols.

From the nurses perspective, it is important to realize that e-mail messages are a form of client

documentation and are stored electronically or printed in hard copy and placed in the clients

health record. E-mails are part of the clients permanent record and, if relevant, can be subject

to disclosure in legal proceedings. E-mail messages are written with this in mind.

Similar to physicians orders received by fax, if physicians orders are received by e-mail,

nurses use whatever means necessary to confirm the authenticity of the orders.

T E L E N U R S I N G

Giving telephone advice is not a new role for nurses. What is new is the growing number of

people who want access to telephone help lines to assist their decision-making about how and

when to use health care services.

Agencies such as health units, hospitals and clinics increasingly use telephone advice as an

efficient, responsive and cost-effective way to help people care for themselves or access health

care services.

Nurses who provide telephone care are required to document the telephone interaction.

Documentation may occur in a written form (e.g., log book or client record form) or via

computer. Standardized protocols that guide the information obtained from the caller and the

advice given are useful in both providing and documenting telephone nursing care. When such

protocols exist, little additional documentation may be required.

Minimum documentation includes the following:

Date and time of the incoming call (including voice mail messages);


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Date and time of returning the call;

Name, telephone number and age of the caller, if relevant (when anonymity is important, this

information may be excluded); and reason for the call, assessment of the clients needs, signs

and symptoms described, specific protocol or decision tree used to manage the call (where

applicable), advice or information given, any referrals made,agreement on next steps for the

client and the required follow-up.

Telenursing is subject to the same principles of client confidentiality as all other types of

nursing care.

Common Questions about Documentation

What information is included in the progress notes?

Progress notes (nurses notes) are used to communicate nursing assessments, interventions

carried out, and the impact of these interventions on client outcomes. In addition, progress

notes are intended to include:

Client assessments prior to and following administration of PRN medications;

Information reported to a physician or other health care provider and, when appropriate, that

providers response;

All client teaching;

All discharge planning, including instructions given to the client and/or family and planned

community follow-up;

All pertinent data collected in the course of providing care, including data collected through

technology such as monitoring devices (e.g., strips produced during cardiac or fetal

monitoring); and

advocacy undertaken by the nurse on behalf of the client.

What is considered timely documentation?


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The timeliness of documentation will be dependent upon the client. When client acuity,

complexity and variability are high, documentation will be more frequent than when clients are

less acute, less complex and/or less variable.

Graphically, this is shown as follows:

Low

Med

High

Acuity

Complexity

Variability

Frequency of documentation

Who owns the health record?

The self-employed nurse or the agency in which the clients health record is compiled is the

legal owner of the record as a piece of physical or electronic property. The information in the

record, however, belongs to the client.

Clients have a right of access to their records and to protection of their privacy with respect to

the access, storage, retrieval and transmittal of the records. The rights of clients and obligations

of public agencies are outlined in the Freedom of Information and Privacy Act and are often

summarized in agency policies.

How does the Freedom of Information and Protection of Privacy Act (FOIPPA) affect

documentation?

The FOIPPA provides the legislative framework for information and privacy rights. This act

applies to all public bodies, including hospitals, health authority boards, CRNBC and similar

organizations. The legislation gives the public a right of access to records held by one of these

public bodies. Individuals have a right of access to personal information about themselves


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(including their health records) and a right to request correction of such information. The act

also prevents the unauthorized collection, use or disclosure of personal information by a public

body.

Is the information in the clients health record confidential?

Yes. Information in the health record is considered confidential. Client consent for disclosure

of this information to agency staff for purposes related to care and treatment is implied upon

admission, unless there is a specific exception established by law or agency policy. Client

consent is required if the contents of the health record are to be used for research or if any

client information is to be transmitted outside the agency.

Nursing documentation must be produced according to agency policy when:

Clients request access to their personal records;

CRNBC, under the Health Professions Act and Regulation needs to inspect or investigate

records; a subpoena is provided (e.g., negligence suit); or a statutory mandate requires the

release of the information (e.g., reporting communicable diseases or child abuse).

Do clients have access to their health record?

Yes. The CRNBC Standards of Practice require that nurses provide clients, in appropriate

circumstances, with access to their health records or assist them to obtain access to these

records. These standards are consistent with the Freedom of Information and Protection of

Privacy Act whereby clients can submit written requests for access to their records or for

information that might otherwise not normally be provided. Refer to agency policy as to the

process to follow when clients request access to their health records.

What happens to third party information when information in a health record is to be

released?


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Nurses may obtain relevant information about a client or an incident from another person, such

as the clients family member or friend. Nurses may also learn information about a third party

that is relevant to the client.

When a clients record has another persons name on it or contains information about another

person especially if the information was given in confidence - the record may need to be

severed before it is released. This means that some portions of the record are removed and

not released to the client requesting the record. For example, if the clients record included the

name of a friend of the client or another client, the section of the record that includes this

information would need to be removed before releasing the record to the client.

How is client information contained in communication books and shift reports

communicated?

Communication books and shift reports are used to alert the health care team to critical

information. These tools are used to direct others to the health record where the pertinent

information is recorded in detail. Relevant health information communicated by these tools is

documented in the health record (College of Nurses of Ontario, 2002).

Should I document incidents where calls are made because of a concern about a specific

client, but are not returned?

It is important to document only facts on client health records. In cases where calls are made

because of a concern about a specific client, a notation of these calls is made in the progress

(nurses) notes. A notation is made aftereach call, regardless of whether the call was returned.

If a call is returned, that is noted.

Under which circumstances are verbal orders appropriate?

Telephone orders

Orders accepted over the telephone are generally made without the physicians direct

assessment of the clients condition. Decisions are based solely on the nurses assessment of


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the client. Any miscommunication or lack of communication could lead to negative

implications for the client. Errors in recording telephone orders can also occur and there is

always the question of who made the error, the physician in ordering, or the nurse in recording.

Despite these concerns, there are times when telephone orders may be the best option for the

client .In these cases, the nurse makes himself/herself aware of the agencys policy with regard

to accepting and documenting telephone orders. Orders left on answering machines are not

acceptable.

Documenting Telephone Orders

Write down the time and date on the physicians order sheet.

Write down the order given by the physician.

Read the order back to the physician to ensure it is accurately recorded.

Record the physicians name on the physicians order sheet, state telephone order,

print your name, sign the entry and identify your status (e.g., RN).

On-site verbal orders

On-site verbal orders also have the potential for error and are avoided unless in an emergency

situation, such as a cardiac arrest. Nurses need to be aware of the agencys policy with regard

to accepting and documenting on-site verbal orders. Of nursing staff, only registered nurses

take verbal orders (and telephone orders) pertaining to medications.

Orders taken verbally and recorded by pharmacists

In B.C., pharmacists can accept and record verbal orders from physicians to dispense

medications. In these circumstances, nurses can carry out the orders from the label on the

dispensed medication.

Should chart pages or entries be recopied?


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Under no circumstances are chart pages or entries recopied. Errors are corrected according to

agency policy. If information is difficult to read, then add information in a note to chart or

note to file.

How are after the fact notes developed by nurses for potential use in the future handled?

There are occasions when nurses write notes after the fact (e.g., one day later, one week

later), most often to provide clarification following an incident or an unexpected client

outcome. Nurses usually write these notes while the event is current in the nurses memory, in

case of an investigation or lawsuit at a later date. It is recommended that nurses do not keep

these notes at home but provide them to a supervisor or risk manager within the agency for safe

keeping.

How long do health records need to be kept?

Self-employed nurses and agencies should have policies on the retention of health records and

client documentation. Current legislation needs to be considered in the development of these

policies. Legislation differs, depending upon the setting. In all settings, records that contain

references to blood or blood products must be maintained in perpetuity (MOH communication,

1996/1997). In other words, these records must be kept forever.

In acute care hospitals, documents contained in the health record may be considered primary,

secondary or transitory. Records are kept for the following time periods (from date of

discharge):

Primary documents (e.g., physicians orders, nursing admission assessment, consultations,

discharge summary, and notice of death) - 10 years

Secondary documents (e.g., most diagnostic reports, medication records, flow sheets and

nurses notes) six years

Transitory documents (e.g., diet report, graphic chart) - one year


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Depending upon agency policy, records of minors may be required to be kept longer than the

time periods listed above.

In community care, public health and mental health settings, client records of adults are

generally kept for 10 years and minors for 25 years from the date of service.

Some exceptions apply to the timeframes listed above, requiring certain practice settings to

have longer retention periods (e.g., forensic mental health). Nurses need to be aware of agency

policy and legislation impacting these retention periods.

What records are self-employed nurses required to keep?

Self-employed nurses must have a documentation system. What is recorded will depend on the

type of service offered. Forms can be simple and still address nursing assessment, plans,

interventions and client outcomes. The CRNBC Practice Standard Self-Employed Nurse

(pub.413) provides direction on documentation requirements for self-employed nurses and is

available from the CRNBC website.

Bibliography

Ares vs. Venner. 14 D.L.R. (3rd) 4, reversing 70 W.W.R. 96, (S.C.C.) 107, 112, 114, 115, 117,

120, 127 (1970).

B.C. Health Care Risk Management Society (2002). Guidelines to Section 51 of the Evidence

Act. Victoria: Author.

Canadas Health Informatics Association. (2001). Guidelines for the protection of health

information. Toronto:Author. Coleman, A. (1997). Where do I stand? Legal implications of

telephone triage. Journal of Clinical Nursing, 6, 227-231.

College of Nurses of Ontario. (2002). Nursing documentation standards. Toronto: Author.

(PAM: Charting) Ferguson vs. Hamilton Civic Hospital. 144 D.L.R. (3rd ed.) 214 (1983).

Kolestar vs. Jeffries. 59 D.L.R. (3rd ed.) 367 (1974)


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