CNO - Documentation Flashcards
Whether paper, electronic, audio or visual - it is used to monitor a client’s progress and communicate with other care providers. It also reflects the nursing care that is
provided to a client.
Documentation
Reflects the client’s perspective, identifies the caregiver, and promotes continuity of care by allowing other partners in care to access the information.
Doccumentation
Communicates to all health care providers the plan of care, the assessment, the interventions necessary based on the client’s history, and the effectiveness of those interventions.
Documentation
Demonstrates the nurse’s commitment to providing safe, effective, and ethical care by showing accountability for professional practice, showing the care the client receives, and transferring knowledge about the client’s health history.
Documentation
Demonstrates that the nurse has applied within the therapeutic nurse-client relationship the nursing knowledge, skill, and judgment required by professional standards regulations.
Documentation
Whether documenting for individual clients, or for groups or communities, the documentation should provide a clear picture of:
■ the needs or goals of the client or group
■ the nurse’s a___ based on the needs assessment
■ the outcomes and e___ of those actions.
a-ctions
e-vauluation
Can be used to evaluate professional practice as part of quality improvement processes.
Data from documentation
Can be used to determine the care and services a client requires or was provided.
Data from documentation
Through this, nurses can review outcome information to reflect on their practice and identify knowledge gaps that can form the basis of learning plans.
Data from documentation
In nursing research, ___ from documentation is used to assess nursing interventions, evaluate client outcomes, identify care, and documentation issues, and advance evidence-based practice.
data
True or false: nurses are required to make and keep records of their professional practice.
True
As regulated health care professionals, nurses are accountable for ensuring that their documentation is accurate and meets the ___ practice standards.
College’s
Failing to keep records as required, falsifying a record, signing or issuing a document that the member knows includes a false or misleading statement, and giving information about a client without consent, all constitute professional ___ under the Nursing ___.
misconduct / Act
Nursing documentation may be accessed in ___ investigations and other legal proceedings.
College
The diagram illustrates the inter-relationships supporting nurses in the provision of safe, effective, and ethical care.
The ___ fact sheets, practice standards, and guidelines support nurses in the provision of safe, ethical, and effective care.
College’s
Support nurses with policies, procedures, and decision-support tools.
Organizations
As self-regulated professionals, they are accountable to the practice standards that the College sets.
Nurses
The CNO provides ___ standard statements and corresponding indicators that describe a nurse’s accountabilities when documenting.
3
1) Communication
2) Accountability
3) Security
CNO’s 3 standard statements for documentation
CNO
College of Nurses Ontario
Describe broad principles that guide nursing practice.
Standard statements
Help nurses apply the standard statements to their particular practice
environment.
Indicators
Nurses ensure that documentation presents an accurate, clear, and comprehensive picture of the client’s needs, the nurse’s interventions, and the client’s outcomes.
Communication
A nurse meets this standard by:
■ ensuring that documentation is a complete record of nursing care provided and reflects all aspects of the nursing process, including assessment, planning, intervention (independent and
collaborative), and evaluation
■ documenting both objective and subjective data
■ ensuring that the plan of care is clear, current, relevant, and individualized to meet the client’s needs and wishes
Communication
A nurse meets this standard by:
■ minimizing duplication of information in the health record
■ documenting significant communication with family members/significant others, substitute decision-makers, and other care providers
■ ensuring that relevant client care information kept in temporary hard copy documents (such as Kardex, shift reports, or communication books) is captured in the permanent health record. For example, if the electronic system is unavailable, the nurse must ensure that information captured in temporary documents is entered in the
electronic system when it becomes available again
Communication
A nurse meets this standard by:
■ providing a full signature or initials and professional designation (RPN, RPN [Temp], RN, RN [Temp] or NP) with all documentation
■ providing full signature, initials, and designation on a master list when initialling documentation
■ ensuring that hand-written documentation is legible and completed in permanent ink
Communication
A nurse meets this standard by:
■ using abbreviations and symbols appropriately by ensuring that each has a distinct interpretation and appears in a list with full explanations approved by the organization or practice setting
■ documenting advice, care, or services provided to an individual within a group, groups, communities,or populations (for example, group education sessions)
■ documenting the nursing care provided when using information and telecommunication technologies (for example, providing telephone
advice)
Communication
A nurse meets this standard by:
■ documenting informed consent when the nurse initiates a treatment or intervention authorized in legislation
■ advocating for clear documentation policies and procedures that are consistent with the College’s practice standards
Communication
Nurses are accountable for ensuring their documentation of client care is accurate, timely, and complete.
Accountability
A nurse meets this standard by:
■ documenting in a timely manner and completing documentation during or as soon as possible after the care or event
■ documenting the date and time that care was provided and when it was recorded
■ documenting in chronological order
Accountability
A nurse meets this standard by:
■ indicating when an entry is late as defined by organizational policies
■ documenting at the next available entry space and not leaving empty lines for another person to add documentation (when using paper documentation forms)
Accountability
The following is an example of this CNO standard for documenting: when documenting on paper, if there are empty lines the nurse should draw a line from the end of the entry to the signature.
Accountability
The following is an example of this CNO standard for documenting: when using an electronic system, the nurse should refrain from leaving a space in a free-flow text box.
Accountability
A nurse meets this standard by:
■ correcting errors while ensuring that the original information remains visible/retrievable
■ never deleting, altering, or modifying anyone else’s documentation
■ enabling a client to add his or her information to the health record when there is a disagreement regarding care
Accountability
A nurse meets this standard by:
■ documenting when information for a specific time frame has been lost or cannot be recalled
■ indicating clearly when an entry is replacing lost information
■ ensuring that documentation is completed by the individual who performed the action or observed the event, except when there is a
designated recorder, who must sign and indicate the circumstances (for example, a code situation or instances when an electronic system has technical difficulties and someone else enters the information when the system becomes available again)
Accountability
A nurse meets this standard by:
■ clearly identifying the individual performing the assessment and/or intervention when documenting
■ advocating at the nurse’s facility for clear documentation policies and procedures that are consistent with the College’s standards
Accountability
Nurses safeguard client health information by maintaining confidentiality and acting in accordance with information retention and destruction policies and procedures that are consistent with the
standard(s) and legislation.
Security
A nurse meets this standard by:
■ ensuring that relevant client care information is captured in a permanent record
■ maintaining confidentiality of client health information, including passwords or information required to access the client health
record
■ understanding and adhering to policies, standards, and legislation related to confidentiality
Security
A nurse meets this standard by:
■ accessing only information for which the nurse has a professional need to provide care
■ maintaining the confidentiality of other clients by using initials or codes when referring to another client in a client’s health record (for example, using initials when quoting a client’s roommate)
■ facilitating the rights of the client or substitute decision-maker to access, inspect, and obtain a copy of the health record, unless there is a compelling reason not to do so (for example, if disclosure could result in a risk of serious harm to the treatment or recovery of an individual)
Security
A nurse meets this standard by:
■ obtaining informed consent from the client or substitute decision-maker to use and disclose information to others outside the circle of care
■ using a secure method such as a secure line for fax or e-mail to transmit client health information (for example, making sure the fax
machine is not available to the public)
■ retaining health records for the period the organization’s policy and legislation stipulates when required by the nurse’s role (for example, in independent practice)
Security
A nurse meets this standard by:
■ ensuring the secure and confidential destruction of temporary documents that are no longer in use
■ advocating for clear documentation policies and procedures that are consistent with the College’s standards
Security
True or false: if organizational policies conflict with the College’s documentation practice standard, advocate for policies that are consistent with the standards.
True
