Universidad de Sta.

Isabel Vincentian Learning Module

College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN

Chapter 5: Guidelines and Protocol in Documentation

and Health Care Records

OVERVIEW

Chapter 5 addresses the essential role of documentation in health care, outlining guidelines and
protocols that health care professionals must follow to ensure effective communication and quality
patient care. The chapter begins with an introduction to the significance of documentation,
emphasizing its role in accountability, continuity of care, and professional practice.

Key concepts discussed include the 5Cs of documentation: Clarity, Conciseness, Completeness,
Confidentiality, and Chronological Order. These principles guide health care professionals in
maintaining accurate and comprehensive records that are essential for effective communication
among multidisciplinary teams. The chapter also highlights the necessity of collaborative and patient-
centered documentation practices.

The chapter further elaborates on the purposes of professional documentation, such as

facilitating communication among health providers, ensuring accountability, meeting legislative
requirements, and supporting quality improvement initiatives. It underscores the importance of
creating a comprehensive and complete record of care that reflects professional judgment and critical
thinking.

Strategies for maintaining high-quality documentation practices are also outlined, including
organizational support, effective leadership, professional development, and responsive
communication systems. The chapter concludes with a discussion on the need for robust
documentation policies and the importance of regular audits to ensure compliance and enhance the
quality of care.

Overall, the chapter serves as a comprehensive guide for health care professionals, providing the
necessary knowledge and tools to improve documentation practices, ultimately leading to better
patient outcomes and enhanced organizational effectiveness.

LEARNING OUTCOMES

At the end of this lesson, you will be able to:

1. Understand the Importance of Documentation: Recognize the role of

documentation in ensuring accountability, communication, and continuity of
patient care within health care settings.
2. Apply the 5Cs of Documentation: Demonstrate the ability to implement the
principles of Clarity, Conciseness, Completeness, Confidentiality, and
Chronological Order in health care documentation.
3. Utilize Effective Communication Strategies: Identify and employ
collaborative, patient-centered documentation practices that enhance
communication among multidisciplinary health care teams.

No part of this learning module may be reproduced in any form without prior permission in writing from the author. 1
Universidad de Sta. Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN

4. Adhere to Legal and Ethical Standards: Explain the legal and ethical
obligations related to patient confidentiality and documentation, including
compliance with regulations such as HIPAA.
5. Evaluate Documentation Practices: Assess the quality of documentation
based on established guidelines and principles, and identify areas for
improvement in clinical practice.
6. Implement Quality Improvement Strategies: Develop and propose
strategies to enhance documentation practices within health care organizations,
ensuring they meet the needs of patients and comply with regulatory
requirements.
7. Conduct Audits and Monitoring: Understand the processes for auditing and
monitoring documentation to maintain high standards of care and ensure the
accuracy of health records.

INTRODUCTION TO DOCUMENTATION IN HEALTH CARE

Healthcare documentation, encompassing patient care information, is an essential component of
clinical practice, reflecting clinician accountability and enhancing communication among experts.
It must comply with the 5Cs: clarity, utilization of recognized medical terminology, standard
acronyms, and correct punctuation and spelling, guaranteeing that all healthcare providers
comprehend the patient's treatment plan.

Therefore, documentation should follow the 5Cs namely:

1. Clarity: Use recognized medical terms and conventional acronyms to precisely

delineate a patient's condition.
2. Conciseness: Maintain documentation succinct, terse, and focused.
3. Completeness: Refrain from leaving gaps between entries to document delayed
entries. Fill out all forms with accurate information.
4. Confidentiality: Safeguard and maintain the privacy of patient information.
Formulate data security rules and confidentiality agreements in accordance with
HIPAA regulations.
5. Chronological Arrangement: Systematic medical records, organized
chronologically by documentation specialists, are easily accessible, manageable,
and facilitate patient care documentation and legal inquiries, ensuring swift
navigation and readability. (Rajagopal, 2021)

Effective organization facilitates the resolution of legal inquiries pertaining to treatment

and enhances the readability and navigability of records.

In addition the 5Cs, documentation must be collaborative and patient-centered.

The objective of patient care documentation is to convey ESSENTIAL INFORMATION PERTINENT
TO PATIENT CARE and treatment among healthcare practitioners. Multidisciplinary progress
notes represent an exemplary practice through which healthcare professionals can communicate
effectively and monitor the patient's care and treatment status. Clinical personnel must
proficiently communicate with individuals and groups through both formal and informal channels,
ensuring that paperwork is precise and upholds confidentiality.

No part of this learning module may be reproduced in any form without prior permission in writing from the author. 2
 Universidad de Sta. Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN

• Documentation can be used to evaluate professional

practice as part of quality assurance and quality
Documentation must be patient-focused
improvement mechanisms such as performance reviews,
and based on professional observation
audits and accreditation processes, legislated inspections
and assessment that does not have any
and critical incident reviews (WHO, 2007).
basis in unfounded conclusions or
• Accurate and comprehensive documentation is a valuable personal judgements. (WHO, 2007).
source of data for data coding, health research and a
valuable source of evidence and rationale for funding and
resource management (WHO, 2007).

• It should be assumed that any and all clinical

documentation will be scrutinized at some point.

PURPOSE OF GUIDELINES
WHO (2007) provides guidelines for employers, policymakers, managers, and clinical staff to
ensure professional obligations, accountability, and legal requirements in communicating patient
health information and clinical interventions in the public interest. Professional documentation
includes written and electronic health records, audio and video tapes, emails, facsimiles, images,
observation charts, check lists, communication books, shift/management reports, incident
reports, clinical anecdotal notes, and personal reflections. Other documentation may be relevant
to evidence of clinical practice and of interest to employers, regulatory authorities, the Ministry
or Department of Health, courts, funding bodies, or the general public.

This may include:

• policies, procedures, and protocols

• critical incident / occupational health and safety reports statistical and research data
• reports related to service and funding agreements staffing rosters personnel files
• performance appraisals
• clinical assessments
• published reports/papers.

Purposes of Professional Documentation

1. Communication

Documentation in medical records serves a foundation for communication among

healthcare practitioners. It serves as a continuous and contemporaneous record,
detailing the care provided, the planned treatment and care, and the outcomes of that
care. Documentation enables health professionals and other care providers to utilize
current, consistent data and care objectives to guarantee continuity of care.
Comprehensive, precise, and factual documentation provides a reliable, enduring
account of patient treatment and accurately reflects the patient's healthcare history.

No part of this learning module may be reproduced in any form without prior permission in writing from the author. 3
Universidad de Sta. Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN

2. Accountability

Documentation evidences accountability and records the clinician's professional practice.

It can be utilized to ability for care provision and to resolve disputes or complaints
regarding the requisite care. The clinician's documentation may be utilized in
performance assessments, internal organizational inquiries, and/or legal proceedings
(including civil litigation or coronial inquests).

3. Legislative requirements

Nurses and midwives are obligated to create and maintain records of their professional
practice in compliance with their profession's standards of practice as well as
organizational policy and procedure. Legislation from many nations may stipulate the
recording and retention of specific information and content.

Neglecting to preserve and uphold specific documentation records as mandated,

falsifying documents, supplying incomplete or erroneous documentation, and endorsing
or issuing a document that one knows or suspects to be false or misleading may all be
considered unprofessional by a regulatory authority.

4. Quality improvement

Documentation can be used to assess professional practice as part of quality assurance

procedures including performance evaluations, audits and accreditation processes,
mandated inspections, and critical incident reviews. Clinical professionals may utilize this
information to evaluate their practice and implement evidence-based improvements.
Documentation provides proof of the high quality of care and services provided to the
public.

5. Research

Medical record documentation is a major source of data for health researchers. It

encompasses details regarding clinical interventions, evaluates patient outcomes, and
serves as a concise record essential for dependable research data and evidence-based
practice.

6. Funding and resource management

Data extracted and classified from medical record data may be utilized as a useful tool
for determining the sort of treatment that patients require, the services given, and the
efficiency and efficacy of care. Any of these concerns may impact financing and resource
allocation. Accurate and comprehensive documentation of interventions serves as a
crucial source of evidence and rationale for finance and resource management.

7. Maintaining Quality Documentation Practice

Clinical personnel, medical records staff, and hospital administrators collectively bear the
responsibility and legal obligation to establish and uphold environments that enable
proficient clinicians to deliver quality, evidence-based outcomes for patients,
collaborating to foster a high-quality practice setting. These documentation guidelines

No part of this learning module may be reproduced in any form without prior permission in writing from the author. 4
Universidad de Sta. Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN

advocate for employers, medical record and clinical workers, and others to adopt
strategies, policies, and procedures that enhance effective documentation practices in
the workplace.

Strategies to maintain quality documentation practice include;

a. Organizational Support
• Effective systems to facilitate accurate and concise documenting of practice
in medical records.
• Appropriate policies and procedures in connection to successful
documentation systems, practices, and processes management of patient
health information
• Risk management measures that promote good documenting of practice
(including incident management)
• Ensuring ample time is allotted to document effectively and evaluate past
paperwork as part of patient care
b. Leadership
• Encouraging clinical personnel to participate in decision-making about the
selection, implementation, and evaluation of documentation systems.
• Putting in place quality improvement strategies for effective documentation
• Promotion of documentation as an essential component of professional
activity and accountability. Resources
• Access to a suitable physical setting that promotes and improves the
efficiency and confidentiality of documents.
• Reliable, accessible, and well-maintained equipment.
• Documentation systems that are relevant to/for the context in which the
care is provided.
c. Professional Development
• Appropriate staff information, education, and orientation about documenting
systems and processes
• Processes for performance management that give opportunities to enhance
documentation procedures.
d. Communication Systems
• Documentation methods that encourage proper information exchange
throughout the interdisciplinary team.
• Effective information sharing while safeguarding and maintaining patient
confidentiality.
• Integrated progress notes for all disciplines and care providers to utilize
Where applicable, secure electronic data and communication methods
• Appropriate methods for patients to have access to information about their
care.
e. Responsive to Change
• Documents systems and practices that are adaptable to change (eg in
relation to changing models of care, legislation)
• Systems that are responsive to changing patient population demands and
can accommodate them

No part of this learning module may be reproduced in any form without prior permission in writing from the author. 5
Universidad de Sta. Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN

8. Documentation Policy
Medical record officers should make certain that they have established policies,
procedures, and quality assurance processes in place that clarify:
the legislative documentation requirements the minimal documentation requirements
✓ documentation format and kind (including acceptable documentation tools
and forms)
✓ the clinical staffs’ duties and obligations in terms of documentation
✓ the organization's approved abbreviations (including their agreed meaning
✓ any criteria for witnessing or countersigning paperwork (as well as the
meaning and duty for doing so); devoted to these behaviors)
✓ documents access, storage, archiving, and retention requirement
✓ requirements for spoken directives to be documented and telephone
advice/information to be provided; and
✓ the need for secrecy and privacy.
9. Monitoring of documentation
An audit procedure is one aspect of effective risk management. An audit procedure will
be essential for monitoring quality and standards of care, as well as the capacity to
generate correct and full coded data from accessible paperwork and records. The basis
for review is audit tools built at the local level to monitor documentation standards. The
obligation to keep patient information secret also extends to documentation audit
processes.
Organizations are urged to design and execute an acceptable documentation policy, as
well as to audit and monitor documentation and record keeping on a regular basis.

Clinical Competence in Relation to Documentation

Appropriate documentation promotes;

▪ a high standard of clinical care
▪ continuity of care
▪ improved communication and dissemination of information between and
across service providers
▪ an accurate account of treatment, intervention and care planning
▪ improved goal setting and evaluation of care outcomes
▪ improved early detection of problems and changes in health status
▪ evidence of patient care.
A clinician's documentation should be able to demonstrate;
▪ a full account of the clinician's assessment of the patient and the care
planned and provided
▪ relevant information in relation to the patient's condition at any given time
and the interventions and actions taken to achieve identified health
outcomes and/or respond to actual or potential adverse events
▪ evidence that the clinician met their duty of care and taken all reasonable
decisions and actions to provide the highest standard of care
▪ evidence that the clinician met their duty of care and that any actions or
omissions did not compromise the patient’s safety or identified health
outcomes

No part of this learning module may be reproduced in any form without prior permission in writing from the author. 6
Universidad de Sta. Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN

▪ a record of all communications with other relevant others in relation to the

patient

GUIDING PRINCIPLES FOR DOCUMENTATION (WHO, 2007)

Guiding Principle 1: Comprehensive and complete record

Clinical staff have a professional obligation to maintain documentation that is clear,
concise, and comprehensive, as an accurate and true record of care.

Professional documentation by clinical professionals is required to guarantee

safe and effective care. Documentation serves as a record of the care given, along with
the provider's professional judgment and critical thinking utilized.

Documentation acts as evidence of each staff member's unique and essential

contribution to healthcare. It constitutes the basis for proof of care that can be
employed for research, legal evaluation and adjudication, resource distribution, and
primary communication among healthcare practitioners.

Comprehensive and complete documentation and record keeping

❖ clear, concise, complete record of clinical care including, assessment, plan of action
outcomes and evaluation of care)
❖ factual, accurate, true and honest record
❖ avoids duplication of information
❖ legible and non-erasable, permanent, retrievable, confidential, patient-focused and
nonjudgmental
❖ representative and reflective of professional observations and assessment
❖ timely and completed as close as possible after episode of care or event
❖ a complete record including completed forms, charts, methods and systems
❖ chronological record of care (late entries recorded as soon as possible as to rectify
the absence)
❖ prefaced with date and time of care or event (including recording of late entries,
changes or additions)
❖ identifying details of person who provided / documented care
❖ identifying of source of information (including information provided by another
health care professional or provider)
❖ inclusive of signatures (or initials) and professional designation of person recording
information
❖ contains meaningful and relevant information (avoids meaningless phrases such as
'slept well or usual day')
❖ minimize transcription of data
❖ easily interpreted over time and after significant time has elapsed
❖ avoid use of abbreviations (other than those approved and documented in
organizational policy by the Medical Record Department)
❖ detailed documentation in relation to critical incidents such as patient falls, harm to
patients, or medication errors.

No part of this learning module may be reproduced in any form without prior permission in writing from the author. 7
Universidad de Sta. Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN

Guiding Principle 2: Patient centered and Collaborative

Documentation is patient-centered, patient-focused, collaborative and appropriate to
the setting in which the care is provided and the purpose for which the information
recorded

Documentation must be patient-focused. Clinical documentation may record

diverse information within and across services and settings. Given the diversity of care
provided, clinicians must consider the purpose of documentation and how, by whom
and for what purpose that information is to be used.

Effective documentation systems require regular review and revision.

Patient centered documentation and record keeping

❖ documentation systems and practices appropriate to the specific needs of the
patient/patient population and context of the care.
❖ appropriate documentation systems to support shared documentation processes.
❖ a record of independent and collaborative actions with other health professionals or
care providers (e.g. those ordered by another appropriate health professional)
❖ contemporary, secure, resource efficient documentation systems
❖ documentation systems relevant to the setting in which the care occurs (including
patient held records, electronic records, and mobile record systems)
❖ identification of objective and subjective data in documenting assessment of the
patient needs/ health status
❖ individualized, comprehensive and current plan of care
❖ based on professional observation and assessment that does not have any basis in
unfounded conclusions of personal judgements
❖ identifies problems that have arisen and actions taken to rectify / address
❖ frequency of documentation consistent with professional judgement in relation to
complexity/stability of patient, organizational policy, standards, and legislation
❖ documented valid consent of any clinician proposed intervention or operation
❖ accessible relevant previous/other documentation (including patient history, long
and short-term intervention, diagnostic investigations most recent previous
documentation by other clinical staff
❖ appropriate supporting documentation systems and forms
❖ documentation of intervention via telephone (including information obtained and
advice given)

Guiding Principle 3: Ensure and maintain confidentiality

Documentation systems (including electronic systems) will ensure and maintain patient
confidentiality, in all care settings.

Clinicians have legislative, professional, and ethical obligations to protect patient confidentiality.
It is essential that the confidentiality of that information be safeguarded and shared only as
necessary to protect the interests of the person and to ensure the best outcomes of care. This
includes maintaining confidential documentation and patient records.

No part of this learning module may be reproduced in any form without prior permission in writing from the author. 8
Universidad de Sta. Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN

Electronic information, mail and communication systems are increasingly used as effective
means of maintaining and transferring documentation and information in the health care
environment. Precautions must be taken to ensure that clinical staff are fully informed of
appropriate, safe, and secure use of electronic information systems.

It should be assumed that any and all clinical documentation will be scrutinized at some point.

Confidential documentation and record keeping

❖ ensure and maintain the confidentiality of the patient
❖ develop and implement practices that protect confidentiality of information and data
when documenting in a record (including charts)
❖ records stored and archived confidentially
❖ confidentiality of electronic documentation and information
❖ systems and practices are in place that maximize the confidentiality of documentation
and records in diverse settings
❖ systems for sharing information with others ensures only relevant information with
relevant others (also required to maintain confidentiality)
❖ ensuring copies are used, managed stored and/or destroyed appropriately ensure copies
are readable (including photocopies/faxes)
❖ patient records are secure from unauthorized access, loss or theft during transfer,
transmission (ie electronic transfer) or transportation
❖ disposing of documentation (where appropriate to destroy) in a manner which maintains
confidentiality (eg confidential bins / shredding)
❖ those accessing (or seeking to access) documentation have the authority to access it.
❖ meets requirements for storage and disposal scheduling.
❖ In relation to electronic documentation systems, the following are important
❖ maintaining the confidentiality of passwords or any other access information
❖ changing a password as per the organization's policy or more frequently if security risk
has been identified
❖ using passwords that are not easily deciphered (eg date of birth that can be accessed in
personnel record)
❖ being aware and up to date on policies and procedures related to access to confidential
information
❖ fully logging off when not using the system or when leaving a terminal
❖ maintaining confidentiality of any hard copy information reproduced from the electronic
system
❖ protecting the confidentiality of information as it is displayed on monitors (including
consideration of the location and direction of monitors)
❖ never deleting information
❖ only accessing information for which the clinician has a professional need to access
❖ using only secure electronic information and communication systems approved by the
organization
❖ use of confidentiality statements and warnings on email transmissions (i.e. only to be
read by intended recipient)
❖ verifying that the information is legible and complete when receiving electronic
documentation (e.g. medical orders being confirmed by fax)
❖ ensuring the recipient has been informed so as to retrieve faxed documentation as soon
as possible.

No part of this learning module may be reproduced in any form without prior permission in writing from the author. 9
Universidad de Sta. Isabel Vincentian Learning Module
College of Health Sciences HEALTH CARE ETHICS
Nursing Program Abbie Mae SJ. Panday, RN

REFERENCES:
Australian Commission on Safety and Quality in Health Care (2017). National Safety and Quality
Health Service Standards: Guide for Hospitals (2nd Ed.). Sydney: ACSQHC.

Blair, W., & Smith, B. (2012). Nursing documentation: Frameworks and barriers. Contemporary
Nurse, 41(2), 160-168

Collins, S. A., Cato, K., Albers, D., Scott, K., Stetson, P. D., Bakken, S., & Vawdrey, D. K. (2013).
Relationship between nursing documentation and patients' mortality. American Journal of Critical
Care, 22(4), 306-313.

De Marinis, M. G., Piredda, M., Pascarella, M. C., Vincenzi, B., Spiga, F., Tartaglini, D., Alvaro, R.,
& Matarese, M. (2010). If it is not recorded, it has not been done!? consistency between nursing
records and observed nursing care in an Italian hospital. Journal of Clinical Nursing. 19, 1544-
1552.

Häyrinen, K., Lammintakanen, J., & Saranto, K. (2010) Evaluation of electronic nursing
documentation-Nursing process model and standardized terminologies as keys to visible and
transparent nursing. International Journal of Medical Informatics, 79 (8), 554-564.

Jefferies, D., Johnson, M., & Griffiths, R. (2010). A meta-study of the essentials of quality
nursing documentation. International journal of nursing practice, 16(2), 112-124.

Johnson, M., Jefferies, D., & Langdon, R. (2010). The Nursing and Midwifery Content Audit Tool
NMCAT): a short nursing documentation audit tool. Journal of nursing management, 18(7), 832-
845.

Kargul, G. J., Wright, S. M., Knight, A. M., McNichol, M. T., & Rajagopal, R. (2021). What Are
The 5 Cs In Medical Record Documentation
https://www.mosmedicalrecordreview.com/blog/what-are-5-cs-in-medical-record-
documentation/

Riggio, J. M. (2013). The hybrid progress note: Semiautomating daily progress notes to achieve
high-quality documentation and improve provider efficiency. American Journal of Medical Quality,
28(1), 25-32.

World Health Organization (2007). Guidelines and Protocol in Documentation. WHO Publications

-End of this Module-

THANK YOU, BSN 2 STUDENTS.

No part of this learning module may be reproduced in any form without prior permission in writing from the author. 10