Practice Standard

• Documentation

What is documentation?

Documentation is any written or electronically generated information about a client that describes the care or service provided to that client. It is an essential part of nursing practice.

Documentation serves three purposes:

1. Facilitates communication
2. Promotes safe and appropriate nursing care
3. Meets professional and legal standards.

The Documentation practice standard sets out the requirements for paper or electronic documentation of client care.

Documenting in electronic health records

Additional considerations for electronic documentation
If you use an electronic health record (EHR), understand that the same documentation requirements apply although there will be different methods to record information. An electronic signature, such as a unique password, code or personal identification number, links the information entered to that individual. When using EHRs, it's important to maintain the security of your electronic signature and check your organization's policies on protecting confidentiality and security.

• Create a strong password and change it frequently
• Do not share your password or other access information with anyone
• Log off when you leave the terminal or finish using the system
• Make every effort to protect your monitor/screen from being seen while you are working
• Report unauthorized use of an electronic signature or access to the appropriate person in your agency

Meeting the professional standards through documentation

Examples:

• Understand the purpose of and reasons for accurate and effective documentation and ensure that relevant client care information is captured in the permanent health record
• Indicate accountability and responsibility by adding your signature and appropriate title to each entry you make in a client record
• Document client assessments, decisions about client status, plans, interventions and client outcomes consistent with the BCCNM Standards of Practice
• Individualize care plans to meet the needs and wishes of client and keep the plan of care clear, current and useful
• Use documentation to share knowledge about clients with other nurses and health care professionals
• Document relevant communication with the client's family or substitute decision-maker
• Safeguard the security of printed or electronically displayed and stored information and 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
• Assess your documentation practice and undertake activities to improve practice and meet learning goals
• Advocate for and /or help to develop agency policies and practices for electronic documentation that are clear and consistent with BCCNM standards

FAQs

What are some key considerations related to client records for NPs in primary care networks?

Primary care practices require NPs to create and retain comprehensive client records, including a client profile. They must also comply with BC legislation including:

• Freedom of Information and Protection of Privacy Act
• Personal Information Protection Act
• Limitation Act

NPs should seek legal advice from the Canadian Nurses Protective Society, or their legal counsel, to ensure they meet all of these requirements.

NP should determine who is the custodian/trustee of client records – does the NP, or someone else have this role. NPs who are the custodian/trustee of client records should familiarize themselves with their responsibilities according to:

• Under the Health Professions Act, you must retain clinical records for a period specified by the appropriate regulatory body and their employer. 
• BCCNM bylaws state: Section 185 (1) Except as otherwise required by law, a registrant must ensure that all records in the registrant’s custody or control containing information describing the care provided to a client are retained for not fewer than 16 years following (a) the date of last entry, or (b) the date the client reaches 19 years of age, whichever is later.
• Personal Information Protection Act (PIPA) - governs the collection, use and disclosure of personal information by the private sector. This applies to private organizations, including many primary care practices (see Canadian Nurses Protective Society: information for custodian of records.

If NPs are creating client records in a group or shared client record environment (including electronic medical records), a data-sharing agreement should be in place. This agreement should address issues of ownership, custody and enduring access by individual practitioners and the client, including relocation, retirement, or death of the NP. Where these issues have not been clearly addressed, NPs are encouraged to seek guidance from the Canadian Nurses Protective Society or their legal counsel before contracting to provide NP services.

When I consult with other health care providers (such as other nurses, social workers, dietitians etc.), should I include their name in the progress notes of a client’s chart?

Professional judgment (and employer policy) determines when it's appropriate to document an interaction. For example, running an idea past someone to see what they think is different than asking for direction for a client's care from someone because they have particular expertise, and may not need to be documented. If you consult with another health care provider (HCP) and receive direction and/or orders for your client's care, you should document this.

For example, if you consult with a physiotherapist about mobilizing a client, record the reason for the consultation, name and title of the physiotherapist providing the consultation, your actions and client outcome. Update the plan of care as appropriate.

While other HCPs are responsible for documenting any orders or care they provide to a client, your documentation should accurately reflect the care you provide to a client, including when you've consulted with another HCP, their name and their title. When documenting, include:

• date, time and method of contact (e.g. phone call)
• HCP's name and title (e.g. Matt Smith, NP or Grace Lee, Midwife)
• information you provided to the HCP
• HCP's response
• any resulting orders/interventions that you carry out
• agreed upon plan of action
• client outcomes

Nurses are required to follow and meet the Documentation practice standard with all clients and in all practice settings.

I’m a self-employed nurse. How long do I have to keep my client’s health records?

​Under the Health Professions Act, you must retain clinical records for a period specified by the appropriate regulatory body and their employer.  BCCNM bylaws state:

185 (1) Except as otherwise required by law, a registrant must ensure that all records in the registrant’s custody or control containing information describing the care provided to a client are retained for not fewer than 16 years following (a) the date of last entry, or (b) the date the client reaches 19 years of age, whichever is later.

There are further legal requirements regarding the retention and destruction of health records. Please see British Columbia's Limitation Act, the Medicare Protection Act, and the Personal Information Protection Act. Contact legal counsel if you have further questions.

How much charting am I required to do?

Several factors will determine how often and in how much detail you need to chart:

• organizational policies and procedures
• complexity of your client's health care needs
• acuity of your client's condition
• changes in your client's condition or care needs
• level of risk involved in the treatment or care

Your documentation should provide a clear picture of:

• your client's status including any changes in their condition
• your assessments
• your nursing diagnoses
• the interventions you carried out
• the client's response to the interventions
• any changes to the plan of care
• information and concerns you reported to another health care provider and the provider's response
• teaching provided to the client and/or family
• advocacy carried out on behalf of your client

Your client's condition and care needs are determining factors when deciding how much and what documentation is required. Acutely ill, high-risk clients, those with complex health problems, or those whose condition suddenly changes will require more extensive, in-depth and frequent documentation. For example, a client with post-operative delirium would require more frequent documentation of their care than one who is recovering as expected  from surgery.

Documentation demonstrates that you have applied nursing knowledge, skills and judgment, and met the legal standard of care. Document according to organizational  policy — these policies should reflect legislative and other requirements.

Nurses are required to follow and meet the Documentation practice standard with all clients and in all practice settings.

Resources

• Institu​​te for Safe Medication Practices Canada – List of Dangerous Abbreviations, Symbols, and Dose Designations​