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Reasons for Documentation

Nurses have a legal obligation to document. In Ontario, you must adhere to the practice standard titled Documentation, Revised 2008 (College of Nurses of Ontario, 2019a). This standard will be discussed in more detail later; for now, Table 1 lists some fundamental reasons why documentation is so important.

 

Table 1: Why documentation is so important

Reason

Consideration

Communication, continuity of care, and clinical judgment

Documentation is important because it communicates clinical information about a client including data related to their state of health and illness. The documentation record is a vehicle of communication within the interprofessional healthcare team. By documenting information, the healthcare team is made aware of assessments, interventions, and responses. This allows for a continuity of care for the client that is connected and coordinated throughout their experience. Additionally, the documented data allows for healthcare providers to incorporate this information in clinical judgment and decision-making.

Client safety

Linked with communication is the importance of documentation to ensure client safety. Client safety involves partnering with other healthcare providers and clients to prevent and minimize unsafe acts, reduce harm, and respond accordingly (Canadian Patient Safety Institute, 2017). Actions to achieve client safety involve timely, clear, and comprehensive documentation, which serves to communicate a common understanding among healthcare providers about information known about the client, and it also facilitates effective decision-making. Documentation can include directives and care plans related to client safety, such as the use of bedrails and assistive devices. Documentation of medication administration is important in client safety, as it prevents the likelihood of duplicate administration. Documentation can also alert healthcare providers to findings that require interventions to ensure safety.

Quality improvement

Quality improvement involves constant reflection and commitment to working toward best outcomes associated with healthcare systems that are safe, effective, client-centred, timely, efficient, and equitable (Health Quality Ontario’s System Quality Advisory Committee, 2017). Chart audits and reviews aid with the evaluation of standards associated with high quality care and the appropriateness of care. These quality improvement initiatives can help identify needed changes in practice and foster evidence-informed approaches to practice. For example, a quality improvement study could reveal high rates of incident reports related to falls, which could prompt in-service or training sessions surrounding the prevention of falls.

Funding

Documentation records can influence provincial and federal funding. Certain systems are used to evaluate completed tasks based on documentation records, so it is important to maintain clear and comprehensive records of the care and services provided.

Legal

In addition to supporting high quality and safe client care, it is important to consider the legal aspects of documentation. The client record is a legal document that provides evidence of the assessments conducted on the client and the care and services provided. You and/or the client record may be subpoenaed for proceedings related to cases such as negligent practice, coroner’s inquests, violence, child welfare, and criminal offenses. These proceedings may take place many years after you have cared for a client, so the data you have documented may be the only way to recall the situation. Therefore, your documentation must be clear, accurate, and reflective of the assessment you performed and the care you provided. There is also a saying: “if it’s not documented, it wasn’t done” – your documentation notes must be complete, or it will be presumed that care was not provided.

Research

Nurses and other healthcare providers sometimes review documentation records as part of their research. For example, they may examine factors related to nurse-sensitive indicators/outcomes, which will lead to evidence-informed practice. For example, a research project might focus on RN to RPN ratios on a unit and the association with outcomes such a mortality and morbidity, or it might explore documentation notes to assess how nursing discharge teaching after surgery is related to hospital readmission rates.

Population and clinical health insights

Review of client records can provide insight into specific populations and clinical health issues. For example, reviews of client records can help healthcare providers track data and identify trends across patient groups or institutions. These reviews may provide information related to transmission of diseases and epidemics, effectiveness of interventions, or complications with certain populations. For example, influenza-related hospital admission rates and mortality rates are recorded and tracked each year.

 

 

Points of Consideration

Documentation and Violence

Documentation is critically important in cases that involve violence because the client record may be used as a source of evidence in legal proceedings. Therefore, as a nurse you must clearly and comprehensively document your detailed assessment. It is important that you incorporate direct quotes from the client and place them in quotation marks, even if they are expletives involving profanity and obscenity. Photographic images are also necessary to document cases of physical and sexual violence. In cases of bruising, swelling, lacerations, and/or contusions, use a measurement tool as a point of reference. Consult your institutional policies about photography and record keeping, including guidelines related to designated devices for recording images and how the client is identified in the picture.

 

Activity: Check Your Understanding

 

License

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Documentation in Nursing: 1st Canadian edition by Jennifer Lapum, Oona St-Amant, Charlene Ronquillo, Michelle Hughes, and Joy Garmaise-Yee is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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