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Documentation


​Documentation includes any written and/or electronically generated information about a client that describes the care or service provided to that client. Nurses document timely and appropriate reports of assessments, decisions about client status, plans, interventions, and client outcomes.

 FAQs

How much charting am I required to do?

Several factors will determine how often and in how much detail you need to chart:

  • organizational policies and procedures
  • complexity of your client's health care needs
  • acuity of your client's condition
  • changes in your client's condition or care needs
  • level of risk involved in the treatment or care

Your documentation should provide a clear picture of:

  • your client's status including any changes in their condition
  • your assessments
  • your nursing diagnoses
  • the interventions you carried out
  • the client's response to the interventions
  • any changes to the plan of care
  • information and concerns you reported to another health care provider and the provider's response
  • teaching provided to the client and/or family
  • advocacy carried out on behalf of your client

Your client's condition and care needs are determining factors when deciding how much and what documentation is required. Acutely ill, high-risk clients, those with complex health problems, or those whose condition suddenly changes will require more extensive, in-depth and frequent documentation. For example, a client with post-operative delirium would require more frequent documentation of their care than one who is recovering as expected  from surgery.

Documentation demonstrates that you have applied nursing knowledge, skills and judgment, and met the legal standard of care. Document according to organizational  policy — these policies should reflect legislative and other requirements.

Nurses are required to follow and meet the Documentation practice standard with all clients and in all practice settings.

What information do I include in the progress/nursing notes?

​Use the progress notes to communicate nursing assessments, nursing interventions carried out, and the impact of these interventions on client outcomes. Progress notes should include:

  • client assessments prior to and following administration of PRN medications;
  • information reported to a physician or other health care provider and the provider's response;
  • all client teaching;
  • all discharge planning, including instructions given to the client and/or family and planned community follow up;
  • all data collected in the course of providing care, including data collected through technology such as monitoring devices (e.g., strips produced during cardiac or fetal monitoring); and
  • advocacy undertaken by the nurse on behalf of the client
When I consult with other health care providers (such as other nurses, social workers, dietitians etc.), should I include their name in the progress notes of a client’s chart?

Professional judgment (and employer policy) determines when it's appropriate to document an interaction. For example, running an idea past someone to see what they think is different than asking for direction for a client's care from someone because they have particular expertise, and may not need to be documented. If you consult with another health care provider (HCP) and receive direction and/or orders for your client's care, you should document this.

For example, if you consult with a physiotherapist about mobilizing a client, record the reason for the consultation, name and title of the physiotherapist providing the consultation, your actions and client outcome. Update the plan of care as appropriate.

While other HCPs are responsible for documenting any orders or care they provide to a client, your documentation should accurately reflect the care you provide to a client, including when you've consulted with another HCP, their name and their title. When documenting, include:

  • date, time and method of contact (e.g. phone call)
  • HCP's name and title (e.g. Matt Smith, NP or Grace Lee, Midwife)
  • information you provided to the HCP
  • HCP's response
  • any resulting orders/interventions that you carry out
  • agreed upon plan of action
  • client outcomes

Nurses are required to follow and meet the Documentation practice standard with all clients and in all practice settings.

I called the physician about a concern I had with my client, however, my call wasn’t returned. Do I document this call in the client record?

​Yes. If you call/page a health care provider with a concern about a client, document in the progress notes each call, regardless of whether or not the call was returned. Include the time of the call, the provider's name and their response, or if there was no response. Documentation provides evidence of clinical judgment, evaluation of care provided, and referral to other care providers as appropriate. If a call is not documented, there is no evidence that it was made.

I’m a self-employed nurse. How long do I have to keep my client’s health records?

​Under the Health Professions Act, you must retain clinical records for a period specified by the appropriate regulatory body and their employer.  BCCNP bylaws state:

356 (1) Except as otherwise required by law, a registrant must ensure that all records in the registrant's custody or control containing information describing the care provided to a client are retained for not fewer than 16 years following (a) the date of last entry, or (b) the date the client reaches 19 years of age, whichever is later.

There are further legal requirements regarding the retention and destruction of health records. Please see British Columbia's Limitation Act, the Medicare Protection Act, and the Personal Information Protection Act. Contact legal counsel if you have further questions.

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