4. Documentation Principles

All health professionals are obliged to document the outcomes of their patient care encounters in a timely and accurate manner. While this is a central premise to producing quality documentation, each organisation will stipulate slightly different documentation guidelines. In this chapter, the general principles for effective paper-based and EHR documentation are presented.

General principles for documentation

General considerations for documenting  include:

• Documentation should detail information such as assessment findings, risks related to care, the plan of care for the person, modifications to the care plan, interventions performed, and an evaluation of care provided.
• Omissions of care need to be documented including the reason why a particular intervention was omitted (e.g., the person refused an intervention).
• Documentation should be written or entered contemporaneously—it should occur at or near the time of the event, episode of care or when the encounter took place. Do not wait until the end of your shift to document, and never document prior to providing care.
• Documentation must be recorded chronologically.
• Documentation must be relevant, individualised, and specific. Avoid being verbose—extraneous information should be omitted.
• Do not ‘double chart’: avoid duplicating information on multiple forms including repeating information that has been documented on a care plan or clinical pathway in your progress notes.
• Only use abbreviations and symbols that are included on an approved list of the organisation where you are attending professional experience placement. Do not use abbreviations if you are unfamiliar with the organisation’s list of approved abbreviations as there is the risk that an abbreviation may be misinterpreted by others (e.g., the abbreviation  LOC could mean ‘level of consciousness’  or ‘loss of consciousness’). If in doubt, write the word or statement in full.
• The information must be recorded on an approved clinical record document/program.
• If a retrospective entry is made, you must include the date and time in which the event occurred and the date and time that the entry was made.
• Avoid criticising others in your documentation.
• Never correct another health professional’s documentation, even if it is inaccurate.

Tips for improving objectivity

• Only document your own observations and actions. Do not document the observations and actions of other health professionals or on their behalf except in situations where you are a designated recorder, such as being a scribe during a Medical Emergency Team (MET) call.
• Avoid using words such as ‘fine’, ‘good’, ‘poor’, ‘normal’, ‘large’, ‘abnormal’, ‘regularly’, ‘improved’. Instead, report objective data, specific dimensions, amounts or measurements,  and use recognisable systems of measure (e.g., peripheral pulses 2/3 bilaterally in all limbs, 2cm x 2cm bruise, voided 400 mL in the last 6 hours) as this information is more meaningful and quantifiable to others.
• Use anatomical landmarks to report findings (e.g., right upper quadrant of abdomen).
• Report what you can observe not your opinion or interpretation of the situation (e.g., avoid using vague statements such as ‘appears’, ‘looks like’, ‘seems’; see Table 4).
• When including others’ accounts of the situation (e.g., the person’s report of pain or nausea), place these statements in quotation marks.

Considerations when documenting by hand

• Ensure each page of the document includes the person’s name, date of birth, and unique record number (URN).
• Patient identification labels can be used but they must not be placed over the top of an existing label.
• Prior to commencing an entry, check that the health record chart you have selected is the correct one by confirming the person’s name, date of birth and URN.
• Make sure your writing is legible so that it can be read and understood by others. Consider printing if your cursive writing style is difficult for others to read.
• Write in complete sentences and ensure your entry is free from grammatical and spelling errors as such mistakes may lead to unnecessary or missed interventions.
• Black, insoluble ink must be used when documenting unless another colour has been stipulated and approved (e.g., when documenting for a specific observation). Black ink is used as it is less like to fade than other colours over time and it also yields the best photocopies.
• Gaps within the record or entry should be avoided:
  • If there is insufficient space to write a word in a progress note,  draw a line and continue your note in the next space. Draw a line to fill in any space after your signature and designation at the end of the note.
  • If the health record is unavailable at the time of documenting resulting in a gap in the progress notes, draw a diagonal line through the blank page or section to prevent other staff from using this space.
• The date should be written in dd/mm/yyyy format and times must be written using the 24-hour clock (also called military time; see Figure 1).
• When documenting vital signs, medication administration, or other procedures, you should note the time that the task was performed.
• Each progress note entry should include information about the date and time that the entry was made.
• Errors in written documentation must remain visible. Do not scribble over the error or use correction fluid. Unless there is a specific organisational policy, draw a single line through the error and initial it. Some organisations have policies such as writing the word “error” above or near the error and indicating the date and time the correction was made.
• At the end of the entry, the author must sign their name followed by their printed surname and initials and designation (e.g., registered nurse, midwife, enrolled nurse, nursing or midwifery student).
• Additional details such as information about an external agency or a contact number may be added after the signature where appropriate.
• Health professional students must have their documentation witnessed by a registered health professional (e.g., a nursing or midwifery student must have a registered nurse/midwife review and countersign their documentation.

Figure 1: The 24-hour clock and standard time

Considerations when documenting in an EHR

• EHRs capture your digital identity and time stamps of your activities.
• EHRs differ in terms of layout and interface. Structured fields (e.g., vital signs parameters) must be entered according to the specific value format of the field. When entering data into unstructured fields (e.g., progress notes), follow the guidelines for handwritten documentation.
• Do not share your password with others.
• Do not enter data using somebody else’s password.
• Do not walk away from the computer once you are logged in.
• If using a template for progress notes, ensure you update it so that it is individualised and provides an accurate description of the care provided for the person.