Professional Documents
Culture Documents
SSW_PD2009_028
Functional Sub-Group:
Clinical Governance
Corporate Governance
Summary:
Approved by:
July 2009
July 2012
N/A
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:
Page 1 of 8
CONTENTS
1.
Introduction
2.
Policy Statement
3.
Principles / Guidelines
3.1 Guiding Principles
4.
5.
Performance Measures
6.
Page 2 of 8
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)
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.
Page 3 of 8
2.
Protect nurses and midwives if they are called upon to explain the care they
have given to a patient in any circumstance.
Policy Statement
Nursing and midwifery documentation is a process in which the patients experience
from admission to discharge is recorded in a manner which enables all clinical staff
involved in the patients care to detect changes in the patients condition and the
patients 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 patients
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
Nursing and midwifery documentation must contain the actual work of nurses
including education and psychosocial support
Guiding Principle 3
Page 4 of 8
Guiding Principle 6
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).
Page 5 of 8
Ibid.
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).
7
Page 6 of 8
4.
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.
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.
10
Page 7 of 8
Frank Stromberg, M., A. Christensen, et al. (2001). Nurse Documentation: not done or
worse, done the wrong waypart 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.
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