Documentation Principles

In Newfoundland and Labrador, the Newfoundland and Labrador College of Nurses is the regulatory body for nurses with a mandate to protect the public through regulation of the profession in accordance with nursing legislation. This document applies to all nurses in NL.

Purpose

The purpose of this document is to identify the principles that form the basis of documentation by nurses. These principles apply to documentation in all practice settings including care provided virtually.¹

Specific requirements related to where, when, what and how nurses document will be dictated by several factors, reflecting the diversity of nursing practice and practice environments. These factors include (but are not limited to) the complexity of client care, employer policies², the practice environment, documentation methods or formats, and technologies.

This document is to be used in conjunction with professional standards, standards of practice, ethical codes, relevant legislation, and evidence-informed best practices.

Introduction

Documentation is a nursing action that produces a written and/or electronic account of pertinent client data, nursing clinical decisions and interventions, and the client’s responses in a health record. Documentation reflects the application of nursing knowledge, skills, and judgment, and the client’s perspective. Documentation establishes accountability, promotes quality nursing care, facilitates communication between healthcare providers, informs the plan of care, and conveys the contribution of nursing to health care. Documentation may also be required for legislative compliance.

Principles

Documentation is a component of care. Documentation is an integral part of nursing practice and occurs following the provision of care. Care is not complete until documentation is complete.

Documentation supports the safe provision of care.

Documentation must be concise, objective, legible, chronological, and must provide sufficient information for the seamless delivery of safe and competent care. Documentation enables health care professionals to identify the care that was provided and by whom, any changing patterns in client health status, and the outcomes or evaluations of that care.

Documentation includes all aspects of the nursing process.

The nursing process provides a systematic and sequential guide to planning and providing care. The plan of care identifies a client’s health care status (assessment) and actual or potential health problems (nursing diagnosis), establishes a plan to intervene in meeting the identified needs (planning), identifies nursing actions (implementation), and allows for determination of the effectiveness of the plan (evaluation) in meeting the identified needs.

Documentation includes client-related communications with other health care professionals.

Client-related communication can include written, electronic³, and verbal communications. Documenting communications provides clarity regarding the plan of care and identifies the avenues that were pursued to ensure client care needs or services were met, including response(s) received and unsuccessful attempts.

Nurses are responsible and accountable for documenting the care they provided.

Care provided by other care providers is documented by those individuals. Designated recorders may be identified in select circumstances (e.g., code blue, operating room) when the care provider is unable to document the event as it occurs. Documentation includes information reported to the nurse by others and reflects what was reported, and by whom.

Documentation occurs at the time the care was provided or as soon as possible afterward.

Documentation is not completed before care is provided. Documentation occurs as close as possible to the time of the provision of care to enhance the accuracy and the overall credibility of health records. In situations where documentation is not timely⁴, a late entry is required.

Complexity and risk influence the frequency of documentation.

The frequency of documentation is influenced by the complexity of a client’s health status, the degree of risk involved in a treatment or component of care, changes to the plan of care, when clients move from one place to another (e.g., admission/discharge, transfer, or transport), or from one care provider to another. Employer policies may identify a required frequency of documentation as well as the format⁵ used in the practice area.

Nurses safeguard client privacy and confidentiality in all forms of documentation.

Nurses take measures to safeguard the privacy, security, and confidentiality of a client’s personal health information and health record, including in accordance with applicable legislation.

Documentation demonstrates respect for client’s choice(s).

Nurses have an ethical responsibility to respect a client’s informed choice, even if these choices may pose a risk to a client’s overall health. Respectful documentation is devoid of value judgments about a client’s choices and behaviors.

Conclusion

Documentation is an integral part of professional nursing practice. Adherence to the principles for documentation is a requirement in meeting professional responsibilities and accountabilities.