NSHA Clinical Documentation Policy

Question 1

Understand what is expected regarding using abbreviations

Answer 1

*Abbreviations must be minimized and used with caution, especially in medication orders. The

• NSHA policy recommends adherence to the Institute for Safe Medication Practices (ISMP) “Do Not Use” list to prevent misunderstandings.

*For example, abbreviations like “QD” (once daily) are discouraged to avoid confusion

Question 2

Understand what is meant by “Altering the Heath Record” and if it is acceptable or not

Answer 2

• Altering records, including backdating, omitting significant details, or editing another provider’s notes, is strictly prohibited.
• Late entries are permissible but must be labeled clearly with the time and date of the original event to maintain accuracy.
• Corrections should be visible, such as crossing out mistakes with a single line and initialing the change.

Question 3

Understand the two “Guiding Principles” in this document

Answer 3

*Comprehensive Record: Documentation must reflect all aspects of client care, enabling health professionals to develop and evaluate care plans.

• Chronological Order and Accuracy: Ensuring a chronological record enhances clarity and continuity.
• Individual Accountability: Each entry should be signed, dated, and reflect the author’s professional designation, underscoring personal accountability.
• Supporting Research and Quality Improvement: Clinical documentation serves as a valuable resource for care evaluation, quality improvement, and evidence-based practices

Question 4

Understand when you need to use progress notes vs. using flow sheets.

Answer 4

• Progress Notes: Used for significant findings, abnormal results, and care outcomes requiring detailed documentation.
• Flow Sheets: Designed for routine, expected care tasks, such as vital sign monitoring, where standardized entries are appropriate.

*Both formats ensure a comprehensive, organized view of patient care

Question 5

Understand the Documentation Standards in Appendix A

Answer 5

-Standards include using only black ink or approved electronic tools for legibility, using metric units, maintaining chronological order, and avoiding unapproved abbreviations.

-Red ink may be used on specific medication administration records for emphasis (e.g., underlining concerns) but is generally not recommended due to potential legibility issues after scanning.