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Compliance with this policy directive is mandatory of 8

Policy Directive

Documentation: Nursing and Midwifery Services - Minimum

Standards for Documentation Document No: SSW_PD2009_028 Functional Sub-Group: Clinical Governance

Corporate Governance Summary: These minimum standards identify the guiding principles

required to produce quality nursing and midwifery documentation that records the patient’s experience of their condition and care from admission to discharge in any facility within Sydney South West Area Health Service (SSWAHS).

Approved by: Area Director of Nursing & Midwifery Services Publication (Issue) Date: July 2009 Next Review Date: July 2012 Replaces Existing Policy: N/A Previous Review Dates: N/A Note: Sydney South West Area Health Service (SSWAHS) was established on 1 January 2005 with

the amalgamation of the former Central Sydney Area Health Service (CSAHS) and the former South Western Sydney Area Health Service (SWSAHS).

In the interim period between 1 January 2005 and the release of single Area-wide SSWAHS policies (dated after 1 January 2005), the former CSAHS and SWSAHS policies were applicable as follows:- • SSWAHS Eastern Zone : CSAHS • SSWAHS Western Zone: SWSAHS

Sydney South West Area Health Service Policy No: SSW_PD2009_028 Date Issued: July 2009


DOCUMENTATION: NURSING AND MIDWIFERY SERVICES - MINIMUM STANDARDS FOR DOCUMENTATION CONTENTS 1. Introduction 2. Policy Statement 3. Principles / Guidelines

3.1 Guiding Principles 4. Legal Requirements for All Nursing and Midwifery Documentation 5. Performance Measures 6. References and Links



DOCUMENTATION: NURSING AND MIDWIFERY SERVICES - MINIMUM STANDARDS FOR DOCUMENTATION 1. Introduction

The Minimum Standards for Nursing and Midwifery Documentation has been developed to assist nurses and midwives in Sydney South Western Area Health Service (SSWAHS) to produce quality nursing and midwifery documentation that is consistent throughout all facilities. It presents a set of guiding principles that aims to ensure an accurate and concise method of documenting nursing and midwifery care and complying with legal requirements. The guiding principles have been developed systematically by senior clinicians working in SSWAHS and are based on the best and most currently available evidence. The purpose is to highlight what nurses and midwives should or should not write when documenting information concerning the patient.

The guiding principles provide direction to nurses and midwives in every area of practice and focus on what is written by nurses and midwives at all levels in the nursing and midwifery progress notes of the current Health Care Record.1

Other forms of documentation such as those contained within the medical history of the patient, the nursing and / or midwifery care plan, all observation charts, clinical pathways, handover sheets, and admission and discharge documents are outside the scope of these guiding principles.

This document should be read in conjunction with nursing documentation policies in each facility of SSWAHS as well as Changing the way nurses and midwives document their care: Guiding principles for patient-centred nursing and midwifery documentation (i) The Risks Addressed by this Policy

Clinical Risks: Inadequate or inappropriate documentation about a patient’s condition and their response to care leads to a breakdown in communication that has the potential to cause errors. This could result in delays in treating complications and could adversely affect the outcome of a patient’s care.

Corporate Risks: Information provided through inappropriate documentation could affect the outcome of legal proceedings.

(ii) The Aims / Expected Outcome of this Policy

Quality nursing and midwifery documentation is expected to: • Provide evidence of care and the patient’s response to that care; • Be an important source of reference between nurses, midwives, and other

members of the health care team; • Facilitate the continuity of quality care by keeping all members of the team

informed of the patients’ current health status; • Improve outcomes for patients; and

1 Registered Nurses Association of Ontario (RNAO), Toolkit: Implementation of Clinical Practice Guidelines (2002 [cited); available from http://www.rnao.org/Page.asp?PageID=924&ContentID=823.



• Protect nurses and midwives if they are called upon to explain the care they have given to a patient in any circumstance.

2. Policy Statement

Nursing and midwifery documentation is a process in which the patient’s experience from admission to discharge is recorded in a manner which enables all clinical staff involved in the patient’s care to detect changes in the patient’s condition and the patient’s response to treatment and care delivery. This allows treating teams to make decisions about the best treatment options for the patient based on accurate, objective, and current information.

Documentation is an essential part of the nurses’ and midwives’ care of their patients but is often viewed as a burdensome activity. Uncertainty about what is required to produce quality nursing and midwifery documentation has resulted from numerous changes initiated from legal precedent or public inquiries.

The Minimum Standard for Nursing and Midwifery Documentation challenges nurses and midwives to focus on their patients when they are documenting nursing care. It requires nurses and midwives to document the patient experience from the patient’s point of view, rather than writing from a position that either favours the nurse, the midwife, or the institution.2

The resulting objective assessment describes how the patient views their reason for admission, their response to care and other interventions, as well as any other information that the patient relates to the nurse or midwife.

3. Principles / Guidelines

3.1 Guiding Principles of Quality Nursing and Midwifery Documentation

Guiding Principle 1 • Nursing and midwifery documentation should be patient centred Guiding Principle 2 • Nursing and midwifery documentation must contain the actual work of nurses

including education and psychosocial support Guiding Principle 3 • Nursing and midwifery documentation is written to reflect the objective

clinical judgment of the nurse or midwife Guiding Principle 4 • Nursing and midwifery documentation must be presented in a logical and

sequential manner Guiding Principle 5 • Nursing and midwifery documentation should be written

contemporaneously, or as events occur

2 O. Karkkainen, T. Bondas, and K. Eriksson, "Documentation of Individualized Patient Care: A Qualitative Metasynthesis," Nursing Ethics 12, no. 2 (2005).



Guiding Principle 6 • Nursing and midwifery documentation should record variances in care

within the health care record Guiding Principle 7 • Nursing and midwifery documentation must fulfil legal requirements

Details regarding these principles are outlined below:

Principle 1: Nursing and midwifery documentation should be patient centred

This requires that the nurse and midwife document the patient’s comments about their condition and the nurse’s or midwife’s own perceptions of the patient’s status and care. All comments about the patient should be written from the patient’s point of view.

Principle 2: Nursing and midwifery documentation must contain the actual

work of nurses including education and psychosocial support Nurses and midwives must document all aspects of the patients’ care, including any emotional support or education given to the patient. Studies of verbal communication demonstrate that nurses and midwives have a complex understanding of their patients’ condition and care, but often this understanding is not found in the nursing or midwifery documentation.3 Nursing and midwifery have a long tradition of over-reliance on the spoken, rather than written, word as can be seen in many handovers where there is neither reference to nursing and midwifery documentation nor the bedside charts.4

Principle 3: Nursing and midwifery documentation is written to reflect the objective clinical judgment of the nurse

Nursing and midwifery documentation is to be presented in an objective form, which demonstrates the nurses’ or midwife’s clinical judgment. Nurses and midwives must avoid making sweeping conclusive statements prefaced by words such as ‘appears’ and ‘seems’. To avoid this, nurses and midwives should document what they see, not what they think.5

What the nurse and/or midwife should document is observable facts to describe the patient’s condition and the nurse’s or midwife’s care.

Principle 4: Nursing and midwifery documentation must be presented in a logical and sequential manner

To demonstrate that the patient has received all necessary care, the nurse or midwife must document all nursing and midwifery problems, indicating what interventions have been implemented and the outcomes of these interventions. If the problem remains, the nurse or midwife must demonstrate that the problem was re-evaluated and further solutions were sought. This emphasises the problem solving aspect of nursing and midwifery documentation.

3 Jane Terese Brooks, "An Analysis of Nursing Documentation as a Reflection of Actual Nurse Work," Medsurg Nursing 7, no. 4 (1998). 4 A Pearson, "The Role of Documentation in Making Nursing Work Visible," International Journal of Nursing Practice 9 (2003). 5 Patricia J. Staunton and Mary Chiarella, Nursing and the Law, 6th ed. (Sydney: Elsevier, 2008).



Principle 5: Nursing and midwifery documentation should be written contemporaneously, or as events occur

Traditionally nurses and midwives have documented their care at the end of a shift but to ensure that nursing and midwifery documentation is an accurate reflection of the patients’ condition and care, it should be written as events occur. Writing contemporaneously ensures that the nurse or midwife has a better recall of the events and, if an event is overtaken by subsequent events, it is not forgotten. If nursing and midwifery documentation does not take place until the end of a shift, trying to recreate an accurate sequence of events can prove confusing.6 If the entry in the nursing and midwifery documentation is not made when an incident occurs, or is written out of sequence with other entries recording the event, it should be recorded as a ‘late entry.’ Any entry recorded after the shift has finished should also be recorded as a ‘late entry’.7

Principle 6: Nursing and midwifery documentation should record variances in care within the Health Care Record

One of the goals of nursing and midwifery documentation is to communicate information to the entire health care team. Therefore nursing and midwifery care must be documented in a clear and concise manner so that changes in the patients’ condition or care are easily recognisable.8

Additional information about the condition and care of the patient is found in other sections of the Health Care Record, such as the nursing or midwifery care plan or observation charts. The guiding principles actively discourage nurses and midwives repeating information found elsewhere, especially if this information shows that the patients’ condition was stable and unchanged.

Principle 7: Nursing and midwifery documentation should fulfil legal requirements

Nurses and midwives are advised to document their care ‘defensively’, or in a manner that explains the decisions made about the nursing or midwifery care or the nursing or midwifery care given to the patient if the nurse or midwife is called upon to explain their actions in any context. Nurses and midwives must ensure that their documentation gives an accurate account of the care given or the decisions made in relation to that care.9

6 Ibid.

This does not mean that nurses or midwives should list the specific tasks they have performed during the shift for the patient. Nursing and midwifery documentation should present a continuous narrative demonstrating how nurses and midwives understand the patients’ condition and how they have dealt with the various problems that have been presented by this condition. Nurses and midwives should document the outcomes of care.

7 M. L. Murray, M. Lieberman, and K. Olson, "Late Entries: Lack of Consensus in Definitions with Nursing Implications," Journal of Nursing Care Quality 15, no. 3 (2001). 8 M. Frank-Stromborg, A. Christensen, and D. E. Do, "Nurse Documentation: Not Done or Worse, Done the Wrong Way -- Part I," Oncology Nursing Forum 28, no. 4 (2001). 9 "Legal and Professional Kit for Nurses: Section 3 Documentation," (NSW Nurses' Association, 2003).(2003).



4. Legal Requirements for All Nursing and Midwifery Documentation

• Nursing and midwifery documentation must be written legibly. • The patient must be identified by name, health care record number and date of

birth at the top of each page of nursing documentation either by an identifier, such as a sticker, or as written by the nurse.

• All entries must include the date and time (using the twenty-four hour clock) when

documentation occurred and should include the signature, name and designation of the nurse or midwife.

• If using medical terminology, the nurse or midwife must be sure of its exact

meaning. • Incorrect entries must not be totally obliterated. A line should be drawn through

the entry before the writer continues. The nurse or midwife should indicate that they have drawn the line through the entry by placing their initial next to the entry.

• No entry concerning a patient’s care should be made on behalf of another nurse or

midwife.10

• Before using any form of abbreviation, nurses and midwives must ensure that the abbreviation is approved in the individual clinical setting. If there is any doubt, nurses and midwives must not use any abbreviations and write all words in full.

• No blank lines are to be left between entries in the health care record.

It should also be noted that Health Care Records are not legal documents, but under the rules of evidence, anything that is physically created has the potential to be called into court if it is relevant to any matter being dealt with by the court.11 Nursing and midwifery documentation is called upon frequently by the courts, therefore it is in the interests of nurses and midwives to ensure that they document their patient care in an accurate, objective, and sufficiently comprehensive manner to support oral descriptions of the care given.12

5. Performance Measures

Patient medical records will be audited on a regular basis by wards / units / departments to ensure compliance. Education will be provided to staff who are identified through this process as not being compliant with the Minimum Standards for Nursing and Midwifery Documentation policy.

6. References and links

Brooks, J.T. (1998). ‘Analysis of Nursing Documentation as a reflection of the Actual Nurse Work’. Medsurg Nursing 7 (4): 189-198. SSW_PD2007_001 - Code of Conduct

10 Staunton and Chiarella, Nursing and the Law 190-2. 11 ‘"Legal and Professional Kit for Nurses: Section 3 Documentation," 2. 12 Staunton and Chiarella, Nursing and the Law, 195.



Frank Stromberg, M., A. Christensen, et al. (2001). ‘Nurse Documentation: not done or worse, done the wrong way—part 1’. Oncology Nursing Forum 28(4): 697-702 (Sweden). Karkkainen, O., T. Bondas, et al. (2005) ‘Documentation of Individualized Patient Care: A Qualitative Metasynthesis.’ Nursing Ethics 12, (2): 123-132. (Sweden). Legal and Professional Kit for Nurses: Section 3 Documentation. (2003) NSW Nurses' Association. SSW_PD2007_005 - Legislative Compliance: Organisation, Management and staff Obligations. Mbabazi, P., r. Cassimjee. (1996). ‘The quality of nursing documentation in a hospital in Rwanda’. African Journal of Nursing and Midwifery 8 (1): 31-42. Murray, M. L., M. Lieberman, et al. (2001) ‘Late Entries: Lack of Consensus in Definitions with Nursing Implications’. Journal of Nursing Care Quality 15(3):32-38. Pearson, A. (2003). ‘The Role of Documentation in Making Nursing Work Visible’. International Journal of Nursing Practice 9:271. (RNAO), Registered Nurses Association of Ontario. (2002). Toolkit: Implementation of Clinical Practice Guidelines Available from http://www.rnao.org/Page.asp?PageID=924&ContentID=823. Staunton, Patricia J., and Mary Chiarella. (2008). Nursing and the Law. 6th ed. Sydney, Elsevier.

http://www.rnao.org/Page.asp?PageID=924&ContentID=823�

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