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IMPORTANT
As of Sept. 4, 2018, the following nursing colleges amalgamated to become
the British Columbia College of Nursing Professionals (BCCNP):
• College of Licensed Practical Nurses of British Columbia (CLPNBC)
• College of Registered Nurses of British Columbia (CRNBC)
• College of Registered Psychiatric Nurses of British Columbia
(CRPNBC)
Although the information in the document you are about to access reects our
most current information about this topic, you’ll notice the content refers to
the previous nursing college that published this document prior to
Sept. 4, 2018.
We appreciate your patience while we work towards updating all of our
documents to reect our new name and brand.
Documentation in
Nursing Practice
Workbook
2855 Arbutus Street
Vancouver, BC
Canada V6J 3Y8
College of
Registered Nurses
of British Columbia
Tel: 604.736.7331
T
ol: 1.800.565.6505 (BC)
Web: www.crnbc.ca
Introduction
This workbook offers activities that allow you to apply ideas presented in the
on-line Learning Module. It is organized in four sections.
• Part 1 includes Workbook Activities that are related to various topic areas
addressed in the Learning Module. As you work through the module, you will
be directed to complete a specific Workbook Activity. Part 1 also includes pages
for you to record your thoughts related to learning in this module. There are
two pages: “Thoughts from Reflection Points” provides a space to jot down your
thoughts related to “Reflection Points” included in the Module, while “Insights and
affirmations” provides a space to note new insights related to your documentation
practice. This information will be useful for you in completing your Learning Plan
at the completion of this module.
• Part 2, “Applying My Learning”, includes case scenarios and associated questions.
Completing the questions related to the cases provides an opportunity for you to
apply all of the information that has been offered in the module in the context of
practice-based scenarios. When you have completed the questions, you may wish
to compare your responses with those provided in the “Applying my learning:
Perspectives” located in Part 4.
• Part 3: This section of the workbook provides an opportunity for you to create a
plan for your professional growth. A sample Learning Plan is provided to help you
in this process.
• Part 4 presents sample responses to Workbook Activity # 4 and to the case
scenarios included in Part 2: “Applying My Learning.”
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Part 1
Workbook Activities
Workbook Activity #1
1
page 3documentation in nursing practice workbook
2. Now, consider your documentation example and note down your thoughts related to the following
questions:
• How effectively did you communicate information for other health care professionals?
• Does the information you recorded (and the way you recorded it) support the goal of provision of safe,
appropriate client care by all health care professionals?
• Does your documentation provide evidence that your practice is congruent with BCCNP
Standards for
Practice?
• In the event of some legal proceeding, would your documentation provide sufficient evidence of care
provided such that it is understandable several years from now?
3. What have you learned about your documentation processes in this activity? Note your thoughts here so that
you can come back to them later.
This activity provides an opportunity to explore the purposes of documentation and how effectively your
current documentation practices support these.
1. First, select an example of your ‘everyday’ nursing documentation. There are several ways you can do this. You
may wish to think back over your last day at work, recall a specific client situation and, as far as possible, recall
what you documented related to that situation. Alternatively, you could imagine a ‘typical’ client situation in
your workday and create ‘typical’ documentation for that situation. Or, you may wish to bring an example of
your documentation from you next day at work, and use it to complete this activity. Regardless of the source,
describe that documentation now in the space below.
page 4documentation in nursing practice workbook
Workbook Activity #2
This activity provides an opportunity for you to consider the interrelationships between your documentation,
various directing and influencing factors and client outcomes.
1. Return to the client situation and related documentation that you recorded in Workbook Activity # 1. Using the
conceptual map of documentation included in the module, explore your documentation processes and content
in this situation.
• What factors provided the most direction for your decision to document and the nature of what you
documented? Was it legal considerations? Professional requirements? Personal knowledge, judgments, and
ethical perspectives?
• What did you document? Is the client’s perspective or experience reflected? Did you include assessment data,
as well as your actions? Did you include evaluation and client outcomes? If not, why are these not part of
your documentation?
• If the situation involved interactions with other health care professionals, is that evident in your
documentation?
• Does your documentation support you and other health care professionals in providing safe, appropriate and
ethical client care?
2. Now take a few moments to reflect on this section of the module and Workbook Activity # 1 and #2. What have
you learned about your documentation processes in your nursing practice? Were aspects of your documentation
processes affirmed by this discussion and workbook activity? Or perhaps you have experienced some new
insights regarding the extent to which your documentation fulfills the purposes of documentation in provision
of safe, appropriate and ethical client care?
Record these conclusions on the “Affirmations and Insights” page of this Workbook. At the completion of the
module, you will have an opportunity to use the insights and affirmations gained in various learning activities,
as part of your planning for future professional growth and development.
2
page 5documentation in nursing practice workbook
Workbook Activity #3
In this activity you will explore the direction provided within BCCNP regulatory documents for your
documentation processes in nursing practice. The documents can be accessed by links in the learning module
or directly from www.
bccnp.ca.
1. Begin by reviewing the BCCNP Professional Standards for Registered Nurses and Nurse Practitioners. As you
review the standards and associated indicators, consider how they relate to your documentation processes.
In what ways do the standards and indicators provide direction for competency related to documentation in
nursing practice?
When you have completed this activity, you may wish to compare your conclusions with information
provided in the BCCNP Practice Support Guidelines for Documentation, p8 & 9.
2. Now, please review the BCCNP Practice Standard for Documentation. As you read the Practice Standard, reflect
on the principles and the direction they provide for your documentation processes in your nursing practice.
Does your documentation reflect these principles? Do the principles offer insights or solutions for areas of
documentation that you are unsure about or find challenging? Keep in mind, you will have an opportunity
to explore these principles further in the section of this module that focuses on characteristics of effective
documentation.
3
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Workbook Activity #4
This activity provides an opportunity for you to explore the characteristics of effective documentation by
examining three short scenarios.
Scenario #1
Mr. Ron Brown is a 71 year old gentleman with Type 1 diabetes admitted to hospital for treatment of an ulcer on
his right heel. Diane was assigned to Mr. Brown and Diane also provided nursing care to him yesterday.
Mr. Brown was alert and oriented to person, place and time. He normally had no problems with ambulation.
Mr. Brown wears glasses to read and drive and he has no hearing deficits. He lives alone. Mr. Brown’s discharge
plan is to return to his apartment.
During her morning assessment, Diane noted at 0800 that Mr. Brown had some facial grimacing and he limped
on his right foot when he walked to the bathroom. When asked, Mr. Brown tells Diane “I have pain where the
ulcer is”. Diane probed further to determine the characteristics of Mr. Browns’ pain as constant and throbbing,
and he rated it’s intensity as 6 out of 10. Diane administered pain medication (Tylenol #3- 2 tablets) at 0830.
Diane reassessed Mr. Brown’s pain at 0945 and he rated the intensity at 1 out of 10.
Diane decided to do Mr. Brown’s dressing change at 0950 since Mr. Brown’s pain was controlled. When Diane
removed the old dressing Diane noted a moderate amount of fresh watery, bloody drainage with a small amount
of green-yellow pus drainage. The ulcer area was round and the size was about 3 cm x 4 cm, the area around
the ulcer was red. The ulcer borders were well defined. Most of the wound bed was granulation tissue with a
smaller amount of yellow slough. Mr. Brown had decreased sensation to this area of his foot as he could not feel
the coolness of the solution or feel when Diane was pressing down. An adaptive dressing, 2- 4x4 gauze and ½
abdominal pad were placed on the wound. Mr. Brown did not complain of any discomfort during the dressing
change.
Diane entered the following documentation in Mr. Brown’s record:
0815 Client reports pain right foot. Diane Smith, R.N.
0830 Tylenol #3 two tabs given for complaints of pain. Diane Smith, R.N.
0950 Dressing to right foot changed for moderate amount of bloody Diane Smith, R.N.
drainage with some pus. Wound looks clean and healing. Client
tolerated dressing change well.
1. Critique Diane’s documentation on the care she provided to Mr. Brown. Identify what she did well, and the areas
where she could improve her documentation using the characteristics of effective documentation in this section
as a resource.
4
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Workbook Activity #4 (continued)
2. Imagine you are Diane. Document the care you provided to Mr. Brown correctly in the space below.
Scenario #2
Mrs. Ada Green, an 89 year old widow, lives alone in her two story home. She is recovering from surgery
following an “anterior resection” for bowel carcinoma. She was discharged with a Home Nursing Care referral
for a home transition assessment and wound healing assessment because she developed a post surgical wound
infection while she was in hospital. At discharge from hospital Mrs. Green was alert and determined to remain
independently mobile in her own home for as long as possible. Mrs. Green has Meals on Wheels delivered twice
weekly and private home support twice weekly for assistance with personal care. She is on a regular diet and
is capable of managing her cardiac, pain and antibiotic medications, which her friend has labelled for her. A
neighbour assists with transportation, shopping and social planning. Mrs Green has no family in town.
On the morning of October 12 at 0950, three days after being discharged from hospital, Janie, the Home Care
Nurse, found Mrs Green sitting in her chair looking anxious and somewhat unkempt. She was rocking back and
forth, clutching her abdomen and moaning. When asked she stated “I’m in pain” and “ I can’t seem to catch my
breath”. Her dressings were in disarray, there was a distinct fecal odour, and she was diaphoretic. She admitted
that she had spent the night in her rocker, did not know the time and could not recall when she had last taken
her pills or eaten. Janie took her vital signs and they were as follows: Temperature: 38 degrees Celsius, pulse 110/
minute and regular, blood pressure 100/70 mmHg, respirations 28 breaths/minute and mildly laboured.
1. Imagine you are Janie. Document your assessment of Mrs. Green to this point in the space below.
4
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Workbook Activity #4 (continued)
Scenario #3
Jim, a nurse in the intensive care unit of a tertiary hospital is beginning a busy day with his assigned patient.
Alex, another nurse on the unit offers to help Jim out. Jim tells Alex that it would be a great help if he could give
Mr. White 2 mg. of Morphine IV now as Mr. White indicated that he had some pain when Jim assessed him just
10 minutes ago. Jim had not yet had time to administer analgesic to Mr. White.
Alex checks the order, asks Jim a few more questions about Mr. White, then heads off to get the Morphine from
the narcotic cupboard. He returns and administers the Morphine to Mr. White.
1. Suggest appropriate documentation for this scenario.
2. What other follow up care and documentation would be required in this situation?
Now take a few moments to reflect on this activity. What have you learned about your documentation processes
in your nursing practice? Were aspects of your documentation processes affirmed by this workbook activity? Or
did you experience some new insights regarding your documentation?
Record these conclusions on the “Affirmations and Insights” page of this Workbook. At the completion of the
module, you will have an opportunity to use the insights and affirmations gained in various learning activities,
as part of your planning for future professional growth and development.
4
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Workbook Activity #5
This workbook activity is a self-assessment of your documentation practices. For this activity, you’ll complete a
self-assessment checklist based on the BCCNP Principles of Documentation, the characteristics of effective
documentation and your understanding of documentation approaches. By completing this checklist, you’ll be
identifying your personal strengths in documentation practice and also areas where you need to further develop
your documentation practice.
Regardless of documentation approach,
I always document all clinically significant
information using the nursing process
(assessment, nursing diagnosis, planning,
intervention and evaluation) on the client’s
health record. This includes information or
concerns reported to another health care
provider and, when appropriate, that
provider’s response..
I document the care I personally provide to
the client.
I do not document routine care that other
health care providers provide a client.
I know in which emergency situations I may
document care another health care provider
provides.
My documentation is clear, concise, factual,
objective. My documentation contains
significant details and accurate descriptions.
I avoid generalizations and I avoid vague
descriptors and subjective judgments. I
identify any client comments.
I use only approved abbreviations
My documentation is chronological and timely.
When I am unable to document in a timely
or chronological way, I mark “late entries,”
recording both the date and time of the late
entry and of the actual event.
I want to improve my
practice in this area
YES NO
Selt Assessment Notes
5
page 10documentation in nursing practice workbook
Workbook Activity #5 (continued)
I add my signature and title, or initials as
appropriate, to each entry they make on the
health record.
I document legibly
I document comprehensively, in-depth and
more frequently when clients are acutely ill,
high risk or have complex health problems.
I document care/services provided to a group
and overall observations pertaining to the
group on the appropriate forms. I document
information about individuals in the group on
their personal health records.
I have read and understood the documentation
policies of the agency and unit where I work.
I document using the tools and method(s)
supported by the agency and unit.
I use documentation tools appropriately,
knowing which tools becomes part of the
client’s health record and which do not. I
ensure all necessary information about the
client is documented on the client’s health
record.
I maintain the confidentiality of a client’s
information and client record.
I only access a client record when I have a
professional need.
For nurses who have responsibility for client
records: I retain the client’s record for a
minimum of six years after the client is last
assessed or treated. If the client is a minor, I
retain the record for six years after the client
reaches age 19.
I want to improve my
practice in this area
YES NO
Selt Assessment Notes
5
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Workbook Activity #6
In this activity you will use the information presented in the section related to errors in nursing documentation
to explore your own documentation practices, including planning strategies that will minimize future errors.
1. Take a few moments to review your responses to the reflection points in the section you have just completed.
Based on your insights, select 2-3 errors that you have become aware of within your own documentation
practices. Note them on the following table.
2. For each of these errors, complete remaining columns in the table.
• Begin by considering why this error might be occurring. Did you not understand what was required for
acceptable documentation? Or are there other factors that influence what you document?
• Now consider what concerns you have about this error? Are there legal implications? Or is there a potential
negative impact of client care?
• Finally, what strategies could you put in place that would support you in completing effective and appropriate
documentation?
An example has been provided to get you started.
Briefly describe
error here.
Leaving space for my
initial assessment &
documenting other
events after that space.
Returning 3 hours later to
document my assessment.
What are the legal or
client related implications
associated with this error?
This is not acceptable
legal practice: it exposes
me to the risk of being
accused of falsifying
documentation.
Documenting three
hours after an event
increases the risk of
error.
Note down all reasons/
or factors that make
it challenging for you
to complete accurate
documentation
No time to document
assessment when I do it:
- Need to assess all 6
patients as soon as
possible at the beginning
of the shift.
- Need to get 0800 or
2000 medications done
as soon as possible.
- Need to go to coffee
break and/or do break
relief according to unit
timelines.
Select strategies that will
minimize or negate the
reasons/ factors that are
associated with this error.
1. Could document
that I have completed
assessment when I
do it, then can begin
documenting other
care/ events as required.
Document actual
assessment findings
as late entry, with
appropriate notation.
2. Explore with nurse
manager the possibility
of creating a ‘checklist’
assessment form that
is completed separately
from narrative
documentation of events/
ongoing care.
Error in
documentation
practice
I am concerned
about this error
because …
Reasons that this
error occurs in my
documentation.
Strategies that I can
use to avoid this error in
my documentation
6
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Workbook Activity #6 (continued)
Briefly describe
error here.
What are the legal or
client related implications
associated with this error?
Note down all reasons/
or factors that make
it challenging for you
to complete accurate
documentation
Select strategies that will
minimize or negate the
reasons/ factors that are
associated with this error.
Error in
documentation
practice
I am concerned
about this error
because …
Reasons that this
error occurs in my
documentation.
Strategies that I can
use to avoid this error in
my documentation
6
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Workbook Activity #7
Documentation in Nursing Practice: Planning for Professional Growth
This final learning activity will guide you in developing a plan for future development of your documentation
in your nursing practice. Please see Part 3 in the Workbook for a plan outline and an example.
1. Begin by reviewing “
Affirmations and Insights” insights page in this Workbook. This page includes all the
conclusions you have formed about your documentation in your nursing practice as you have worked through
this module. It is, in other words, a comprehensive self-assessment of all the components that are part of, or
influence, your communication. Now its time to put that to use!
Take some time to read through these conclusions: First, notice and acknowledge your strengths. Then pay
attention to the areas that you have identified as areas for development and growth. As you read these, notice
which ones seem to resonate with you or feel most important to you. Use these conclusions to determine the
goals that will support ongoing growth of your documentation skills and abilities.
2. Create three goals that reflect your focus for development in your communication. Write these in the
appropriate place in “My plan for growth in communication”.
3. The next step is to develop an action plan that will help you meet those goals. Begin by identifying resources
that you could use to assist you in meeting your goals. If you are not aware of specific resources, then begin by
listing the sources you will explore in order to learn what you can do to support your growth toward your goals.
4. Once you are familiar with the learning opportunities that are available to you, create an action plan that
outlines specific strategies you will use, what resources you need in order to implement these strategies (e.g.
who do you need to talk to, learning materials you want to acquire, learning experiences you need to arrange
etc) and, importantly, a target date for completion.
Not sure how to do identify goals and create an action plan? The planning for growth page (in Part 3)
has provided a brief example of this process. As well, it is recommended that you use the BCCNP
Continuing Competence tutorials and written documents to assist you help in this process. You may wish
to review these now.
5. Finally: Add your plan to your Continuing Competence file, workbook or portfolio. And remember to update it
once you have completed the actions!
7
Notes from Reflection Points
page 14documentation in nursing practice workbook
My Documentation in Nursing Practice:
Affirmations and Insights
page 15documentation in nursing practice workbook
Part 2
Applying My Learning
page 17documentation in nursing practice workbook
Case Scenario 1: Melanie
Melanie looked up at the clock – 11am. “Wow,” she thought, “It’s been a busy day and I am not even
halfway through yet!” After 5 years in this Extended Care Unit, she had got used to being busy, but today
seemed to be ‘one of those days’. She was, as usual, the only RN on today in this 36 bed unit, along with
one LPN and four Registered Care Aides. She knew that everyone would be busy: The unit was full and the
current client group required a lot of care - and that made for a heavy workload for everyone.
She paused for a moment to collect her thoughts and decide on the next thing she needed to do. While
her responsibility encompassed all of the clients on the unit, there were four clients that particularly
concerned her today. Two were confused and agitated and required close monitoring, another was dying
and, with his family at his bedside, needed comfort care and support, and finally Mr Bell had been short of
breath and coughing during the night. When Melanie had looked in on him earlier he was breathing at 24/
minute, occasionally coughed up yellowish secretions and had a temperature of 37.6C.
Her thoughts were interrupted when Jasmine, an LPN who had worked on the unit for 10 years, stopped
beside her and said, “Can you come and look at Mr. Bell? He seems to be worse that he was earlier this
morning. I sat him up a bit more and that helped a little, but I am quite concerned about him.” Melanie
nodded and they walked down the hallway to Mr. Bell’s room. At first glance it was clear to Melanie that he
was worse. His face was slightly diaphoretic and she could hear his coarse cough. When she asked him how
he was feeling, he replied, “I feel pretty tired. This coughing is wearing me out.”
She nodded and said, “I can see that. If it’s OK with you, I would like to have a closer look at you.” She
counted his respiratory rate at 26/minute and then had a quick listen to his chest. She noted that he had
coarse crackles in both posterior and anterior lower lung fields. His temperature was 37.7C.
Melanie bent slightly closer to him and spoke gently. “Mr. Bell, I can see that you are not feeling well and
that you are tired. Your chest sounds kind of rattly and you have a bit of a fever. I am going to call your
family doctor and let him know. I’ll come back as soon as I have done that and let you know what he says.”
Melanie called Dr Simms and explained the situation, outlining the change in Mr. Bell’s condition over
the previous 24 hours. In response, Dr Simms suggested that Mr. Bell “probably has the flu that’s going
around” and instructed Melanie to “keep an eye on him” and to “call him back if she was concerned”.
Melanie hung up the phone and pulled Mr. Bell’s chart from the shelf. She made the following entry in his
nursing notes:
“Client seems short of breath. Has a fever. Doctor informed.”
Melanie returned to Mr Bell and, as per the unit’s standing orders, gave him some Tylenol elixir “for
comfort”. She also made sure he was well positioned in bed and then left the room to continue with her
care for other clients. Over the next four hours, she checked in on Mr Bell several times and counted his
respiratory rate, noting that it was still high. At one point she listened to his chest again, noticing that
the crackles had increased. Four hours after her initial phone call, Melanie was quite concerned about
Mr Bell – His respiratory rate was 30/minute, he seemed to be working harder with his breathing, his
chest sounded worse, and his pulse oximeter read 92%. She knew that often when clients were sick like
1
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Case Scenario 1: Melanie (continued)
this, that they would be send the client to ER at the local hospital, however, Dr Simms had indicated he
was happy to be called about his clients, so she decided to call him again and update him. After she had
explained the situation, Dr Simms said “I am leaving my office shortly and have to drive past the care
facility on my way home, so I will drop in and have a look at Mr Bell.”
Melanie reached hung up the phone, glanced at the clock and realized she has several medications that she
was late dispensing. She quickly wrote a note in Mr Bell’s chart, and then left the office area to attend to
the medications.
Client’s breathing looks worse. Doctor notified.
Dr Simms arrived 45 minutes later and assessed Mr Bell. He then wrote an order to start Mr. Bell on
antibiotics and to begin supplemental oxygen via nasal prongs at 3L/minute. Melanie came into the
office as he had just completed writing the orders. “Oh Hi, you’re here,” she said. “What do you think is
happening?” she asked.
He replied, “I think he has the flu, and seems to have a bit of chest infection. I have ordered him some
antibiotics and we can start some oxygen therapy and see if that makes him more comfortable. Can you
check his pulse oximeter readings every two hours. If they fall below 92%, or if you think he is getting
worse, please call an ambulance and send him to the ER.”
As Dr Simms left, Melanie reviewed the orders he had written and faxed the prescription for antibiotics to
the pharmacy. She also updated the documentation in Mr Bell’s chart:
Dr in. Orders received.
1
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Case Scenario 1: Melanie (continued)
Activity
Please answer the following questions. When you have completed this activity, you may wish to compare
your responses with those provided in the “Perspectives” section at the end of this Workbook.
1. Review Melanie’s documentation. In what ways does it meet criteria for effective documentation? What
documentation errors are present? Where there are errors, describe how Melanie should have documented
Mr. Bell’s care in these situations. Provide examples of effective documentation.
2. What factors do you think influenced Melanie’s ability to document appropriately in this situation? What
do you think could be done that would assist Melanie to document effectively in future?
3. What are the implications of Melanie’s ineffective documentation for Mr Bell’s outcomes?
4. Consider the conceptual framework and directives for documentation in nursing practice. What could be
the implications of Melanie’s ineffective documentation for herself?
1
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Case Scenario 2: Rick
Rick Ross, RN, hung up the telephone in the Emergency Department (ED) of Elsewhere General, a 30
bed rural hospital in northern British Columbia. Rick had worked at Elsewhere for 3 years now since
graduating…. 2 of those years had been on the combined medical-surgical ward, and one year as a critical
care/ ED float nurse. Rick was working in the locked ED late this particular evening. The other critical
care educated nurse in the hospital, Janet, had primary responsibility for two patients in the 3-bed close
observation unit located between the med-surg ward and the ED.
There were no patients in the ED, but that would soon change: the paramedics were on their way with
Mr. Hugo Stivic, a 58 year old man who was experiencing chest pain. Mr. Stivic, the paramedics said, was
short of breath, wearing oxygen, and had been given aspirin and three sprays of Nitrospray. Rick looked
thoughtful as he picked up the phone again to call Janet. After hearing Rick’s message, Janet said she would
give report to the ward nurses and be down to help Rick with Mr. Sticvic’s admission. Rick made one
more phone call to the physician on call who, after hearing Rick’s report, said she’d be to the ED within 15
minute. She reminded Rick to institute the hospital’s ‘chest pain protocol’.
By the time Mr. Stivic came through the doors of the ED, Janet had arrived to help Rick. Rick asked Janet if
she would draw up some morphine and prepare a nitroglycerin infusion while he assessed Mr. Stivic. Rick
took Mr. Stivic’s vital signs, noting them on his ‘cheat sheet’, and asked Mr. Stivic about his pain:
• ‘what would he rate his pain on a scale of 1-10 with 10 being the worst pain he had ever
experienced?’… a 7 out of ten
• ‘had his pain decreased with the nitrospray?’…it had gone from 10 to 7
• ‘could he describe his pain?’…it was a crushing pain in the middle of his chest that was making it
difficult to breathe
• ‘did his pain radiate anywhere?’…down his left arm and up into his jaw
• ‘were there other symptoms?’ …yes he was short of breath, diaphoretic and couldn’t breathe
• ‘when did it start?’ just after dinner time a little over an hour ago.
Rick fumbled through the pile of papers that would become Mr. Stivic’s chart. Finding the ED admission
record, Rick documented his pain assessment like this : “1920 hours: Patient arrived in ED experiencing
severe chest pain.”
Janet arrived back at the bedside just as Rick was obtaining blood samples from Mr. Stivic. Janet
administered 2 milligrams of morphine IV to Mr. Stivic in the intravenous initiated by the paramedics,
and she handed the mixed bag of nitroglycerin to Rick who proceeded to hang it and commence the
infusion at 20 mcg/min. While Rick was busy, Janet went to get the ED’s 12 lead ECG machine, returned,
and ran a 12 lead on Mr. Stivic. Rick reassessed Mr. Stivic’s chest pain: he reported that it was now 5/10.
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Case Scenario 2: Rick (continued)
Just then, Dr. Sinclair arrived in the ED at Mr. Stivic’s bedside. She looked at Mr. Stivic’s 12 lead, asked him
a few more questions about the quality and timing of his chest pain, and told Rick to increase Mr. Stivic’s
nitroglycerin infusion to 30 mcg/min (which Rick did). She then told Rick and Mr. Stivic that she was
going to arrange transfer by air ambulance to a hospital where Mr. Stivic could have a procedure called a
Percuatneous Transluminal Coronary Angioplasty.
At 1940 Rick assessed Mr. Stivic’s chest pain again as Jan prepared him for transfer, Rick returned to the
ED record to document the care provided. Here is a copy of the pertinent portion of the ED record:
TIME NURSES’ NOTES SIGNATURE
1920 Patient arrived in ED experiencing severe chest pain RR, R.N.
1924 Bloodwork drawn RR, R.N.
1925 Morphine 2 mg IV given for chest pain RR, R.N.
1926 Nitroglyceryn infusion commenced at 20 mcg/min RR, R.N.
1930 12 lead ECG obtained. Dr. Sinclair arrived. RR. R.N.
1935 Nitroglyceryn infusion increased to 30 mcg/min. RR. R.N.
1940 Patient prepared for transfer to tertiary facility RR. R.N.
2
page 22documentation in nursing practice workbook
Case Scenario 2: Rick (continued)
Activity
Please answer the following questions. When you have completed this activity, you may wish to compare
your responses with those provided in the “Perspectives” section at the end of this Workbook.
1. Consider the characteristics of effective documentation. Identify 3 documentation errors in this scenario.
How should Rick have documented Mr. Stivic’s care in these situations. Provide examples.
2. What factors do you think influenced Rick’s ability to document appropriately in this case? What do you
think could be done to support Rick to document effectively in future
3. What might be the implications of Rick’s ineffective documentation on Mr. Stivic’s outcomes?
4. Consider the conceptual framework and directives for documentation in nursing practice. What could be
the implications of ineffective documentation for Rick?
2
Part 3
Growth Planning
My plan for growth in Documentation
Goals
1.
2.
3.
page 24documentation in nursing practice workbook
Action plan
People or places that I can investigate for learning strategies to help me meet my goals for growth are:
1.
2.
3.
Specific strategies that will help me in meeting my goals are
strategy resources i need
to implement this
strategy
target
completion
date
other thoughts
Reminder: Add your completed action plan to your Quality Assurance Portfolio.
My plan for growth in Documentation:
An example
Goals
1.
2.
3.
page 25documentation in nursing practice workbook
Action plan
People or places that I can investigate for learning strategies to help me meet my goals for growth are:
1.
2.
3.
Specific strategies that will help me in meeting my goals are
strategy resources i need
to implement this
strategy
target
completion
date
other thoughts
Reminder: Add your completed action plan to your Quality Assurance Portfolio.
To become familiar with best practices related to electronic documentation
Talk to Clinical Nurse Educator and/or Nurse Leader on Nursing Unit for suggestions about learning resources
Example: detailed plan
1. Review resources available in
my nursing unit
2. Review BCCNP resources
regarding electronic
documentation.
3. Complete Literature search
using CINAHL
1. None – just look on
the shelves & on the
Intranet at work!
2. Use work or home
computer to do this.
Web site URLs in
Learning resource
section of module
3. Call BCCNP
library for advice
& assistance in
doing this.
1. During my next set
of scheduled shifts
2. By end of this
month
3. By end of next
month.
Could ask the nurse educator
at work – maybe she can help
me with this?
Part 4
Workbook Activities and
Case Perspectives
page 27documentation in nursing practice workbook
Workbook Activity #4
Scenario #1
1. Critique Diane’s documentation on the care she provided to Mr. Brown. Identify what she did well, and
the areas where she could improve her documentation using the characteristics of effective documentation
in this section as a resource.
a. Diane did sign each entry correctly, and she documented in a timely and chronological manner
b. Diane did not include objective data about her pain assessment nor did she include all of the objective
data about the condition of Mr. Brown’s ulcer or his lack of sensation during the dressing change.
c. Diane used some vague subjective expressions: ‘clean and healing’ and ‘tolerated well’ doesn’t convey the
details and accuracy of Diane’s assessment and evaluation of care.
d. Diane did not document the effect of the analgesic she administered to Mr. Brown.
e. Anything else?
2. Imagine you are Diane. Document the care you provided to Mr. Brown correctly in the space below.
Here’s an example:
0800
0830
0945
0950
Client limping on right foot and grimacing. When asked
stated ““I have pain where the ulcer is”. Client rated the
intensity of pain as 6 out of 10.
Tylenol #3 two tabs given for complaints of pain
Client reassessed. Client now rates intensity of pain as 1
out of 10.
Dressing removed from right heel ulcer for moderate
amount of fresh watery, bloody drainage with a small
amount of green-yellow pus. Ulcer is 3 cm x 4 cm, boarders
are well defined with redness noted in surrounding skin..
Ulcer bed is granulation tissue with a smaller amount of
yellow slough. When asked, patient stated he could not
feel pressure applied to the area surrounding the ulcer
and could not feel the coolness of the dressing solution.
Ulcer redressed with adaptive dressing, 2- 4x4 gauze and
1/2 abdominal pad. Client did not complain of pain during
procedure.
Diane Smith, R.N
Diane Smith, R.N
Diane Smith, R.N
Diane Smith, R.N
page 28documentation in nursing practice workbook
Workbook Activity #4 (continued)
Scenario #2
1. Imagine you are Janie. Document your assessment of Mrs. Green to this point in the space below.
Here’s one example:
0950- found client sitting in rocking chair clutching her abdomen, rocking and moaning. A distinct fecal odour
is present around client. Client states she spent the night in her rocking chair. Abdominal dressing no longer
intact. Client stated: “I’m in pain” and “ I can’t seem to catch my breath”. Client not oriented to time of day
and cannot recall when she took her pills of ate last. Vital signs as follows: 38 degrees Celsius, pulse 110 and
regular, Blood pressure 100/70 mmhg, respirations 28 breaths per minute and client is diaphoretic and using
accessory muscles to breathe.
Scenario #3
1. Suggest appropriate documentation for this scenario.
Jim should document his assessment. Alex should document the administration of the Morphine.
2. What follow up care and documentation would be required?
Jim should reassess his patient to ascertain if the analgesic was effective, then document this evaluation.
page 29documentation in nursing practice workbook
Applying My Learning: Perspectives
Case Scenario 1: Melanie
Case Scenario 1: Melanie
Review Melanie’s documentation: In what ways does it meet criteria for effective documentation?
What documentation errors are present? Where there are errors, describe how Melanie should have
documented Mr. Bell’s care in these situations. Provide examples of effective documentation.
In general, Melanie’s documentation addresses the ‘when’ aspects of effective documentation. In spite of
her busy day, Melanie documented in Mr. Bell’s chart when she noted a change in his condition and/or
when she interacted with the physician. In addition, she did this at the time of the event. These actions
both fulfill requirements for timely documentation. The frequency of Melanie’s documentation also
reflects the increase in Mr Bell’s acuity level. She documented three entries in the space of about 6 hours.
Now let’s look more closely at what Melanie documented. Each entry is very brief. While concise
documentation (how) is desirable, it is important that conciseness be balanced with providing adequate
information. In fact, Melanie has omitted important information in her documentation and so the
documentation is incomplete:
• In entry #1 and #2, she has not fully documented Mr Bell’s condition or her actions.
• In entry #1, 2, & 3, she has not documented the content of her communication with Dr Simms, simply
noting that she has called him.
• Melanie has not documented any information related to her ongoing assessment of Mr. Bell that
occurred between the first and second entries.
A second concern related to Melanie’s documentation is that her descriptions of Mr. Bell’s condition are
not factual or objective. (She states he “seems short of breath” and ‘breathing looks worse”).
Here are some suggestions about how Melanie’s documentation could be improved in these situations. It
is possible that your examples of more effective documentation may look somewhat different to this one.
Using these examples as a guide, determine if your suggested changes have addressed the issues we have
identified.
Entry # 1:
Client’s face is pale and slightly diaphoretic. Respiratory rate is 26/min, with use of accessory muscles noted
(shoulders). On anterior and posterior auscultation, breath sounds are clear in upper lung fields, with coarse
crackles in lower lung fields bilaterally. Client states he ‘feels pretty tired’. Coughing occasionally, productive for
small amounts of yellow tinged sputum. Temp: 37.7C orally. Pulse rate 85/min. Blood pressure: 125/68.
Dr Simms notified of client’s current condition and changes over night. Dr advised ongoing observation.
Tylenol elixir 650mg given as per unit protocol.
1
page 30documentation in nursing practice workbook
Applying My Learning: Perspectives
Case Scenario 1: Melanie
Missing entries – documented at time of care
Ongoing assessment should provide updates on previously noted concerns, and add any new information. For
example: Client’s respiratory rate remains at 28/min; work of breathing unchanged. Continues to expectorate
small amounts of sputum.
Entry # 2: (at hour 4)
Client’s face diaphoretic; Respiratory rate 30/min. Use of accessory muscles (shoulders) noted. On auscultation:
coarse crackles audible in right lower and mid lung field, as well as left lower lung field. Client states “he is
really tired.” Coughing more frequently for small amounts of yellowish sputum. Temp 37.2 C, pulse 92/minute.
Blood pressure: 145/75. SpO2 92%. Dr Simms notified re changes in condition since ____ (time of first phone
call). Dr states he will come in to assess client.
Entry # 3
Dr Simms assessed client and orders received. Antibiotics pending from pharmacy. Client commenced on
oxygen via nasal prongs @ 3L/minute. SpO2 96% on oxygen. Pulse 85/min; Blood pressure 135/65. Respiratory
rate 24/min. Respirations less labored, with minimal accessory muscle use noted since oxygen therapy
commenced. Client states he feels ‘more comfortable’ but ‘still a bit short of breath’.
What factors do you think influenced Melanie’s ability to document appropriately in this situation?
What do you think could be done that would assist Melanie to document effectively in future?
Factors that may have influenced Melanie’s ability to document appropriately include the following:
• Perhaps this is Melanie’s usual pattern of documentation? It would be helpful to know if the lack
of detail in her documentation is typical of her documentation or if it is just occurring today – and is
influenced by her workload.
• Her workload: she has several clients she is ‘concerned about’ and it is evident she is experiencing a
‘busier than average’ day.
• The overall acuity of current clients in the extended care unit is ‘higher than normal’. This has increased
workload for all staff, and means there is less opportunity for her to get assistance with her client care.
• Melanie appears to be recording all information in the nurses notes – suggesting that the unit
documentation ‘standard’ appears to narrative –style documentation. While this has advantages of
having all information in one area and also allows for descriptive detail, this type of documentation
takes time. This may be why Melanie’s documented entries were brief.
1
page 31documentation in nursing practice workbook
Applying My Learning: Perspectives
Case Scenario 1: Melanie
Strategies and actions that would assist Melanie to document effectively in the future include:
• Focusing her documentation on relevant information will assist her in finding the balance between
concise documentation and including sufficient detail in her documentation. For example:
- Considering all phases of a client situation in documenting
- Considering if what she documents includes enough detail so that someone who had not been
present could still fully understand the situation.
• Focusing her documentation on factual and objective information: this will assist her in providing
clear, unambiguous, and complete information about client situations.
• Melanie did a reasonable job of documenting in a timely manner for three of the events with Mr. Bell.
Building from that partially established pattern will assist her in timely documentation of all of her
actions, all client data and conversations with other health care professionals.
• Workload management. This is a challenge for most nurses today. While there is no simple answer
to finding time in a busy day for documentation, it is helpful to view documentation as one final
step in any aspect of provision of care for a client – and to not consider the care completed until
documentation is done. Considering the type of documentation that supports nurses to complete
timely and appropriate documentation may be helpful. Would Melanie find it easier to be ‘up-to-date’
with her documentation if there was a standardized documentation tool she could use?
What are the implications of Melanie’s ineffective documentation for Mr. Bell’s outcomes?
Earlier we noted that the brief documentation entries that Melanie made were incomplete. They lacked
full information about Mr. Bell’s condition, did not provide details of her actions and did not include
the nature of the phone conversations she had had with Dr Simms. In addition, the information she
did provide related to Mr. Bell’s condition did not provide a clear, factual ‘picture’ of his status at those
times. From this, it is clear that this documentation would not allow other nurses or other health care
professionals to:
• understand what Mr. Bell had experienced during that time period
• use this information in their own planning related to Mr. Bell’s care.
In other words, Melanie’s inadequate documentation both makes it challenging for other health care
professionals to provide optimal care for Mr. Bell (because they are not fully informed) and, potentially,
also places Mr. Bell at risk for inappropriate care. Melanie’s inadequate documentation can have adverse
effects on Mr. Bell’s outcomes.
1
page 32
Applying My Learning: Perspectives
Case Scenario 1: Melanie
Consider the conceptual framework and directives for documentation in nursing practice. What are the
possible the implications of Melanie’s ineffective documentation for herself?
Like all Registered Nurses, Melanie is required to meet legal, professional and agency directives for
documentation. Given that nurses’ documentation is a legal evidence of care provided and client’s
responses to that care, ‘what’ Melanie documented is a concern. The information missing from her
documentation may be interpreted as evidence that she had not provided safe, appropriate and ethical care
for Mr. Bell in this situation. In addition, the vague nature of her statements related to Mr. Bell’s condition,
could be construed to mean that she was not capable of appropriate assessment. In short, Melanie’s
documentation places her at risk of being accused of not providing adequate care for Mr. Bell if, for some
reason, his situation became the focus of legal proceedings.
According the BCCNP Practice Standard for Documentation, nurses’ documentation is a record of
professional practice and care provided for a client and, as such, provides evidence of whether or not a
nurse has applied the nursing knowledge, skills and judgment according to their BCCNP
Professional
Standards of Practice. The Practice Standard further states that nurses should document “timely and
appropriate reports of assessments, decisions about client status, plans, interventions and client
outcomes” (BCCNP, 2008, p.1). When we consider Melanie’s documentation in light of these directives, it
is evident that her documentation does not align with these requirements. However, when we read the
story of Melanie and Mr. Bell, we can see that she was conscientious and committed in the care she
provided
for him - she assessed him frequently, recognized the significance of his change in condition, and
communicated with his physician regularly to ensure he received appropriate care. And yet, because of the
brevity of her documentation, the vague client descriptions and missing information, her documentation
does not provide evidence of her providing care according to the Professional Standards of Practice. As we
noted above, Melanie’s documentation does not provide evidence of her having provided adequate care; it
also places her at risk of a professional practice inquiry.
Finally, Melanie is required to follow the Extended Care Unit’s documentation policy and the agency’s
directives in her documentation. We do not have information related to these policies in this case, but can
assume that the policies will reflect legal and professional requirements for nurses’ documentation. From
this standpoint, it seems possible or even likely, that Melanie’s documentation does not meet unit or
agency requirements in this situation.
documentation in nursing practice workbook
1
page 33documentation in nursing practice workbook
Applying My Learning: Perspectives
Case Scenario 2: Rick
Case Scenario 2: Rick
Consider the characteristics of effective documentation. Identify 3 documentation errors in this
scenario. How should Rick have documented Mr. Stivic’s care in these situations. Provide examples.
Incomplete documentation (what):
As in scenario #1, concise documentation is desirable, but Rick has omitted important information in his
documentation. Rick does not chart the chest pain assessment he performed as clear concise statements
that describe his assessment, rather he simply charts “patient experiencing chest pain”. Nurses’ charting
often lacks detail that describes accurately the care that was provided. Nurses also often miss documenting
the client’s assessment, but document the interventions that were performed (for example, Rick
documented “Morphine 2 mg IV administered”).
It’s also a common error in documentation to miss documenting the evaluation of interventions. This is
also an error in Rick’s documentation. Although Mr. Stivic’s chest pain has decreased considerably with
intervention, it would be impossible to know this from reading Rick’s documentation.
A good test to evaluate whether your charting is satisfactory is to answer the following
Question. If another RN had to take over this patient’s assignment, do the nurses’ notes provide enough
information for that nurse to maintain consistency of safe, competent and ethical care? Would that RN
know that Mr. Stivic was short of breath and diaphoretic and whether Mr. Stivic’s chest pain had been
relieved, and what intervention worked for him?
Rick did perform a full pain assessment. I’d suggest he chart it like this:
2
TIME
1920
NURSES’ NOTES
Patient arrived in ED wearing oxygen 40% by face mask.
Patient is having difficulty speaking and states he is short
of breath. Patient’s skin is clammy. Patient states he is
currently experiencing chest pain 7/10. Patient states
the pain started after dinner and is ‘a bit better’ since the
paramedics gave him nitrospray. He states it was 10/10
before the paramedics arrived. Patient describes the pain
as ‘crushing’ in the ‘middle of his chest’ that radiates down
his left arm and into his jaw.
SIGNATURE
RR.R.N.
page 34documentation in nursing practice workbook
Applying My Learning: Perspectives
Case Scenario 2: Rick
Further, Rick should have documented the effect, or lack of effect, of both the morphine and nitroglycerin on
Mr. Stivic’s chest pain at initiation and with the increase in dose.
Not identifying a ‘Late Entry’ (how):
Rick didn’t complete his documentation until all nursing actions were carried out, approximately 15 minutes
after he began to provide care for Mr. Stivic. When it is not possible to document at the time of providing care a
‘late entry’ is required. The length of time between care and documentation that is considered ‘late’ should be
defined by agency policy.
Rick should have clearly identified his documentation as ‘late entries’ indicating the time the care was provided
and the time of documentation.
Inappropriate documentation of assisted care (who):
Generally RNs should document the care that they personally and directly provide. Documenting for others
who are providing direct care may lead to inaccurate documentation and this could affect the continuity and
quality of client care. In situations when two nurses or a nurse and another health care provider provide care
or services together (witnessed care), the RN who is assigned to the client should document the actions and the
client’s responses, noting that another RN or care provider assisted.
Rick documents Janet’s care (administration of Morphine and obtaining the 12 lead) but does not identify
Janet as the care provider. This could lead to the erroneous assumption that Rick was not assisted and actually
performed this care.
What factors do you think influenced Rick’s ability to document appropriately in this case? What do
you think could be done to support Rick to document effectively in future.
Influencing factors:
The urgency and acuity of the patient’s status
Mr. Stivic came into the ED experiencing chest pain, and was potentially experiencing a myocardial
infarction. His situation demanded urgent care and interventions had to be carried out quickly to
prevent and further damage to his heart muscle. This context of urgency likely influenced Rick’s ability to
document.
The staffing ratio on the unit
Rick did have Janet’s help when Mr. Stivic was admitted and this was a positive influencing factor on
his documentation. It does seem, however, that a bit more assistance may have given Rick the time to
document more completely and in a timelier manner.
2
page 35documentation in nursing practice workbook
Applying My Learning: Perspectives
Case Scenario 2: Rick
Rick’s knowledge of documentation
Is this Ricks typical pattern of documentation? It would be helpful to know if the lack of detail in his
documentation a pattern in his documentation.
The agency policies on documentation
It’s hard to know in this brief case what ‘style’ of documentation Elsewhere General has adopted. Certainly
many ED records are streamlined and contain checklists for more standard assessment criteria while still
meeting the requirements for effective documentation. It appears, however, that Rick’s documentation
is in a more narrative format. In essence, the style of documentation used at Elsewhere General may
influence Rick’s ability to document effectively.
Supporting Rick’s documentation:
Clear agency forms /policies
Elsewhere General may consider reviewing it’s documentation policies and practices and adopting or
creating clear ED records based on directives that support effective documentation.
Documentation ‘refreshers’
It’s quite possible that Rick is not fully aware of his legal and professional responsibilities surrounding
documentation. Rick could work with his educator to develop a plan to improve his documentation, than
access resources to help him review and/or learn more about effective documentation.
ED staffing
This is a challenge for most health care agencies today. While there is no simple answer it’s likely that more
staff in urgent and emergent situation would permit documentation to occur alongside safe, appropriate
and ethical care.
What might be the implications of Rick’s ineffective documentation on Mr. Stivic’s outcomes?
A major problem was that Rick’s documentation was incomplete. It lacked full information about Mr
Stivic’s chest pain and did not provide details of the evaluation of nursing interventions to relieve his pain.
Rick’s documentation did not provide a clear, factual ‘picture’ of his status or whether it changed with
intervention. From this, it is clear that this documentation would not allow other nurses or other health
care professionals to:
• understand what Mr Stivic had really experienced during that time period
• use this information in their own planning related to Mr. Stivic’s care.
Simply, Rick’s incomplete documentation makes it both challenging for other health care professionals to
provide care for Mr Stivic (because they are not fully informed) and, potentially, also places Mr Stivic at
risk for inappropriate care.
2
page 36
Applying My Learning: Perspectives
Case Scenario 2: Rick
Rick’s documentation did not appropriately describe Mr. Stivic’s care in terms of who assisted Rick nor did
it document accurately the timing of Rick and Janet’s care. These errors would not likely affect Mr. Stivic’s
outcome in this particular case however if Rick repeated these errors in other situations, this lack of factual
documentation may cause challenges for other health care providers trying to maintain consistency of care
in Rick’s absence.
Consider the conceptual framework and directives for documentation in nursing practice. What could
be the implications of ineffective documentation for Rick?
Legal and professional requirements:
Like all Registered Nurses, Rick is required to meet legal, professional and agency directives for
documentation. Given that nurses’ documentation is legal evidence of care provided and client’s
responses to that care, ‘what’ Rick documented is a concern. The information missing from his pain
assessment documentation may be interpreted as evidence that he had not provided safe, appropriate
and ethical care for Mr Stivic. Further, the vague nature of his statements could be interpreted to mean
that he lacked knowledge of appropriate pain assessment or that he did not know to evaluate the effect of
the interventions he provided. In short, Rick’s documentation places him at risk of being accused of not
providing adequate care for Mr Stivic if this situation became the focus of legal proceedings.
According the BCCNP Practice Standard for Documentation, nurses’ documentation is a record of
professional practice and care provided for a client and, as such, provides evidence of whether or not a
nurse has applied the nursing knowledge, skills and judgment according to their BCCNP
Professional
Standards of Practice. The Practice Standard further states that nurses should document “timely and
appropriate reports of assessments, decisions about client status, plans, interventions and client
outcomes” (BCCNP, 2008, p.1). When we consider Rick’s documentation in light of these directives, it is
evident that his documentation does not align with these requirements. His documentation is brief,
provides only a vague description of pain assessment and is missing evaluation of interventions. Rick’s
documentation does not provide evidence of providing care according to the Professional Standards of
Practice. This places him at risk of a professional practice inquiry.
Agency’s directives:
Finally, Rick is required to follow the Emergency Department ’s documentation policy and the agency’s
directives in his documentation. We do not have information related to these policies in this case, but can
assume that the policies will reflect legal and professional requirements for nurses’ documentation. From
this standpoint, it seems possible or even likely, that Rick’s documentation does not meet unit or agency
requirements in this situation.
documentation in nursing practice workbook
2
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