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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 patients 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

Compliance with this policy directive is mandatory

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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

Compliance with this policy directive is mandatory

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Sydney South West Area Health Service

Policy No: SSW_PD2009_028


Date Issued: July 2009

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 patients


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 patients 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 patients 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

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.

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Sydney South West Area Health Service

2.

Policy No: SSW_PD2009_028


Date Issued: July 2009

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

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

O. Karkkainen, T. Bondas, and K. Eriksson, "Documentation of Individualized Patient Care: A Qualitative


Metasynthesis," Nursing Ethics 12, no. 2 (2005).

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Sydney South West Area Health Service

Policy No: SSW_PD2009_028


Date Issued: July 2009

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 patients comments about
their condition and the nurses or midwifes own perceptions of the patients status
and care. All comments about the patient should be written from the patients
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 midwifes 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 patients condition and the
nurses or midwifes 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.

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).

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Policy No: SSW_PD2009_028


Date Issued: July 2009

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 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.

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

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Sydney South West Area Health Service

4.

Policy No: SSW_PD2009_028


Date Issued: July 2009

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 patients 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.


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

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Policy No: SSW_PD2009_028


Date Issued: July 2009

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.

Compliance with this policy directive is mandatory

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