Chapter 5.

Guidelines
and Protocol in
Documentation and
Health Care Records

Ms. Donna S. Carcueva,

MN, RN, USRN, LPT, RM
Introduction
+ Documentation in healthcare includes all form of documentation
by health care professionals recorded in a professional capacity
in relation to the provision of patient care.
Documentation should follow the 5C's
namely:

Clarity Conciseness Completeness

Chronological
Confidentiality
order
Purpose of professional documentation

legislative quality
Communication Accountability
requirements improvement

maintaining
funding and
quality Documentation
research resource
documentation policy
management
practice

monitoring of the
documentation
Strategies to maintain quality documentation
practice include:
+ organizational support
+ leadership
+ professional development
+ communication systems
+ responsive to change
Purpose of professional documentation

legislative quality
Communication Accountability
requirements improvement

maintaining
funding and
quality Documentation
research resource
documentation policy
management
practice

monitoring of the
documentation
Guiding principle for documentation (WHO,
2007)
+ Guiding principle 1: comprehensive and complete record
+ Guiding principle 2: patient centered and collaborative
+ Guiding principle 3: ensure and maintain confidentiality
THANK YOU!