You didn’t become a nurse or midwife to sit in front of a computer (or written health record) to write notes all day. You don't have time either. The more time writing repetitive notes, the less time you have to actually provide the care! You were always told to be clear, concise and accurate but no one really ever showed you how to write it! Everyone seems to use a different system and/or different terminology! You find that you are often writing something merely for the purpose or writing something….if it isn’t written it didn’t happen.
You don’t really want to do it and you certainly don’t enjoy it but…..
…. in reality, documentation is part of client care.
It may not feel that important today…but in 2 years time when you find yourself before a disciplinary or legal investigation….will your documentation set you in good stead to defend your actions and provide inconclusive evidence of the care you provided?
It is interesting (and concerning) that there are at present, no nursing or midwifery professional standards in Australia (correct me if I am in error) outlining something as imperative as professional documenting. (Note: there are government and industry based standards (in each state and territory) for record keeping and client health files but these rarely outline or define nursing and midwifery documentation best practice).
Yet documentation is a vital component of safe, ethical and effective nursing and midwifery practise regardless of the context of care or the form or purpose of the documentation. It provides an account (your professional account) of critical thinking and professional judgement you used in and across all aspects of the nursing process (ie assessment; diagnosis; planning; intervention and evaluation) and partnership between the midwife and the woman.
· reflects the application of nursing knowledge, skills, and expertise
· reflects your judgement and establishes your accountability and responsibility
· is a legal record of events
· is a source of evidence
· is a permanent record
· preserves facts and corroborates and clarifies your recollection/s
· records the unique contribution of nursing and midwifery to health care
Nursing/Midwifery Documentation refers to any and all forms of documentation by a nurse or midwife recorded in a professional capacity in relation to the provision of nursing or midwifery care. It includes written and electronic health records, audio and video tapes, emails, facsimiles, images (photographs and diagrams), observation charts, check lists, communication books, shift/management reports, incident reports or any other type or form of documentation pertaining to that care. It may be clinical data, management or educational information or research analysis. It may also include anecdotal notes or personal reflections by the nurse or midwife. Willis nbsa 2005 (rescinded)
Refers to written or electronically generated information about a client, describing the care of services provided to that client (eg charting, recording, nurses’ notes or progress notes). In other words, documentation is an accurate account of events that have occurred and when they occurred. Clinical documents are defined as legally authenticated (ie attested or signed) and persistent entries in a client’s health record. Nurses may document information pertaining to individual clients or groups of clients. Registered Nurses Association of British Columbia 2003
So What is the Purpose of Professional Documentation?
1. Client Care
The permanence of health records makes them a primary client care tool.
Information increases likelihood client will receive consistent/informed care or service.
Particularly in relation to providing necessary information to ensure consistency/continuity of clients’ care.
Encourages health professionals to assess clients’ progress over time, determine effectiveness of interventions, and identify required changes to care plans.
Ensures all involved in a client’s care have access to reliable, pertinent, and current client information upon which to plan and evaluate interventions.
Provides clarity for other health practitioners and reduces duplication of intervention, facilitates multidisciplinary team processes/practices.
Source of information within and across professional groups and teams.
Communicate assessments about status of clients, interventions carried out and results of these interventions.
Demonstrates the practitioner’s accountability and records their professional practice.
Meets requirement to comply with professional standards, organisational protocols, govt policy.
Demonstrates practitioner has applied knowledge, skills and judgement according to professional standards/best practice.
Reflects/honours ethical concepts of sound practice
Respects client’s privacy, confidentiality, information and circumstances.
May be used in relation to:
· performance management
· internal inquiries
· regulatory proceedings
· legal proceedings
· Freedom Of Information (FOI) requests.
4. Legal Record of Evidence
Its importance cannot be overemphasised.
Thorough, accurate, timely documentation is one of the best defences against legal claims.
Can be used as evidence in court of law, coroner’s inquest, regulatory investigations, disciplinary proceedings.
Documentation can be used as evidence in legal proceedings as a measure of nursing care against
· Best practice/evidence based practice
· A ‘reasonable and prudent’ nurse or midwife…..
5. Risk Management
Promotes highest quality of care through quality assurance/improvement.
Risk management processes are used to identify, assess and reduce risk to clients, visitors, staff and assets (eg financial, equipment, human).
Designed to promote safety by reducing incidence of preventable accident/incident/injury.
It may be used for audits, ethical and disciplinary reviews, accreditation surveys, legislated inspections, critical incident review and ongoing risk management analysis.
More readily able to evaluate client/groups progress, identify client care issues and recommend changes/improvements to practice.
A conceptual process to evaluate professional practice.
6. Research Evidence/Analysis
Serve as a valuable/major source of data for nursing and health related research (eg statistical trending helps to prevent or minimise specific developments such as an increase in infection rates).
Identify long term trends/issues for health services/models/resource needs
used in health research to assess nursing interventions, evaluate client outcomes, and determine the efficiency and effectiveness of care.
The type of research made possible through the information in health records can enable nurses to further improve nursing practice.
Precise, clear and complete documentation is essential to ensure accurate research data.
7. Resource/Workforce Management
Provides a valuable source of evidence and rationale for funding and resource management.
Used for workforce measurement data/projections.
Used to measure/determine client classification systems.
Used for skillmix/workload data and funding /resource allocation.
Source of evidence for funding/resource submissions/grants.
I recommend referring to a number of excellent Nursing Documentation Standards from Canada (the best I've seen). Note: They are equally relevant for Enrolled Nurses (Div 2).
Documenting Care: Standards for Registered Nurses Nurses Association of New Brunswick
Practice Standard: Documentation Nurses Association of New Brunswick
Documentation Guidelines for Registered Nurses College of Registered Nurses of Nova Scotia
Nursing Documentation College of Registered Nurses of British Columbia