Nursing Documentation

Standards

Adapted from CNO

Publication No. 41001

Adapted from CNO Standards 1

Pre-Reflection
 What is nursing documentation?
 What is the purpose(s) of
documentation ?
 What guides documentation?

Adapted from CNO Standards 2

Documentation
 The act of creating records of care
 Actual records themselves
 Integral part of safe and effective
nursing practice
 Record of judgement and critical
thinking used in professional practice
 An account of nursing’s unique
contribution to health care
Adapted from CNO Standards 3
Standards of documentation
 Guide to the knowledge, skills,
judgement and attitudes needed to
practice safely
 Describe what you are accountable
and responsible for each and every
time you document client care

Adapted from CNO Standards 4

Legislative Requirements
 Federal Legislation
 Access to Information Act
 Personal Information Protection and Electronic
Documents Act
 Privacy Act
 Provincial Legislation
 Nursing Act, 1991
 Coroners Act
 Health Care Consent Act, 1996
 Mental Health Act
 Freedom of Information and
Protection of Privacy Act
Adapted from CNO Standards 5
Quality Practice Settings
 Current and accessible documentation
systems
 Clear and effective processes and
policies
 Consideration of who clients are, their
needs and the resources available

Adapted from CNO Standards 6

Purpose of Documentation
 Communication
 Accountability
 Legislative Requirements
 Quality Improvement
 Research
 Funding and Resource Management

Adapted from CNO Standards 7

  Clear, concise and
A nurse maintains comprehensive
documentation  Accurate, true and
that is… honest
 Relevant
 Reflective of
observations, not
unfounded
conclusions;
 Chronological

Adapted from CNO Standards 8

  A complete record of nursing
care provided including;
A nurse maintains assessments; identification of
documentation health issues; a plan of care;
that is… implementation; and evaluation
 Legible and non-erasable
 Permanent
 Retrievable
 Confidential
 Client focused
 Completed using forms,
methods, systems provided

Adapted from CNO Standards 9

  Includes date and time of care
A nurse’s or the event and of the
documentation… recording when it is a late or
forgotten entry
 Identifies who provided the
care
 Contains meaningful
information
 Avoids meaningless phrases
such as “sleeping on rounds
“up and about” “usual day”

Adapted from CNO Standards 10

  Includes what was observed,
avoids statements such as
A nurse’s “appears to” and “seems to”
documentation… when describing observations
 Includes signatures or initials
and professional designation
 Avoids duplication of
information in the health
record

Adapted from CNO Standards 11

A nurse meets the standards by
documenting:
 an assessment of client’s health status and
situation/circumstances;
 client preferences for care and outcomes
 implementation of care plan and/or actions
taken
 an evaluation of nursing strategies and
client outcomes
 both independent and collaborative actions
 familiarizing self with relevant prior
documentation

Adapted from CNO Standards 12

Methods and Formats

 Charting by Exception
 Care Pathways
 Focus Charting (data, action, response)
 Client concern; change in condition, significant
event
 SOAP/SOAPIER
 Problem oriented approach
 Narrative Documentation

Adapted from CNO Standards 13

Documentation Forms

 Worksheets
 Kardexes
 Care Plans
 Flow Sheets and Checklists
 Monitoring Strips

Adapted from CNO Standards 14

Documenting Content

 Assessment
 objective data (observations,
measurements and interventions, actions
or procedures and client’s response)
 Subjective data “My chest hurts”
 Third party information
 Relevant client information obtained from
family or friend
 Collaboration with care providers
Adapted from CNO Standards 15
Documenting Content
 Avoid value judgements
 “client uncooperative” “client depressed”
 Do document observed behaviour
 client chooses not to have bath; shouting
and shaking fist
 client showing signs of depression; not
eating, difficulty getting to sleep, early
waking, staying in room

Adapted from CNO Standards 16

Abbreviations and Symbols

 Effective, efficient if well understood

 If obscure, obsolete, poorly defined,
or multiple meanings-can lead to
serious errors, wasted time and
confusion
 Workplace or agency policies
essential

Adapted from CNO Standards 17

Abbreviations and Symbols

 p.o.  per os - by mouth

 p.r.n.  Pro re nata – as

needed
 h.s.  Hora somni –
bedtime
 @  at

 c  with
Adapted from CNO Standards 18
Documenting for Others
 Person who sees event or performs action documents in
the record, except in situations where there is a
designated recorder
 Nurses document the care they give to show
accountability for actions and decisions
 When assisting another nurse in providing care (e.g. to
bath a client) it is acceptable from one nurse to
document the actions and client responses and note
that another care provider assisted
 In critical incidents (e.g. falls) it is important to name
the assisting care provider

Adapted from CNO Standards 19

Timing

 Document as close to the time and

event occurs as this is considered
more reliable and accurate than info
recorded later and based on long term
memory
 Document chronologically
 Document the date/time of the
documentation and the date/time the
event occurred
Adapted from CNO Standards 20
Forgotten or Late Entries,
Errors and Omissions
 Clearly mark late entry as ‘late entry’
 In correcting errors the original
information must remain visible in the
record
 It is considered professional
misconduct under the Nursing Act,
1991, to document an occurrence
that did not take place or to falsify
details

Adapted from CNO Standards 21

General
 Don’t skip lines
 Usually black ink
 Never delete. Alter or modify anyone else’s
documentation
 Date, time, of the provision of care and the
time of the documentation for all entries
 Clearly identify which entry is being signed
(e.g. draw a line from the end of the entry
to the signature)

Adapted from CNO Standards 22

Electronic Health Records
 Documentation standards remain same
 Maintain confidentiality of passwords and access codes
 Log off when leaving the terminal
 Maintain confidentiality of information
 Protect confidentiality of info displayed on the monitor
 Never delete info
 Only access info for which there is professional need
 Advocate for appropriate education and technical
support

Adapted from CNO Standards 23

Security and Confidentiality
 Clients are entitled to access, inspect and
copy the information in their health record
 The nurse facilitates the rights of clients or
person’s with authority to act on their
behalf, to access, inspect and obtain a copy
 Ensure those seeking access have authority
 Obtain client consent to collect, use and/or
disclose info outside the health care team

Adapted from CNO Standards 24

Transmission of Health Info
 Avoid standard e-mail
 Facsimile transmissions are
convenient and efficient
 Ensure number is correct
 Include confidentiality warning on cover
sheet
 Obtain consent from the client

Adapted from CNO Standards 25

Other Records
 Communication books
 Shift reports
 Incident reports
 Can be requested in legal proceedings

Adapted from CNO Standards 26

Conclusion

 Documentation is an integral part of professional

nursing practice
 Provides an account of nursing’s unique contribution to
health care
 Nurses have a professional obligation to follow CNO
Guidelines, Agency policy and to meet legislative
requirements
 By adhering to CNO standards, nurses are meeting their
professional obligations as self-regulated health
professionals to maintain documentation that is clear,
concise, comprehensive, accurate, true and honest

Adapted from CNO Standards 27