Overview of Professional Communication and Accountability
Purpose of Documentation
Documentation serves to reflect the client's perspective and identify
the caregiver, promoting continuity of care.
It communicates the plan of care, assessments, interventions, and
their effectiveness to all healthcare providers.
Integral to interprofessional documentation, ensuring all team
members are informed about the client's care.
Demonstrates the nurse's commitment to safe, effective, and ethical
care, showcasing accountability in professional practice.
Essential for transferring knowledge about the client's health history
and ongoing care needs.
Importance of Professional Communication
Professional communication is a complex interactive process crucial in
clinical settings for achieving health-related goals.
Outcomes include the development of person-centered health
partnerships and increased satisfaction for patients and families.
Effective communication leads to a better understanding of the
patient's condition and promotes positive health outcomes.
Involves verbal, nonverbal, and written forms, each playing a vital role
in patient care.
Strong communication skills are essential for nurses to advocate for
their patients and collaborate with other healthcare professionals.
Documentation Standards and Methods
CNO Standards on Documentation
Communication: Documentation must accurately reflect the client's
needs, nurse's interventions, and outcomes.
Accountability: Nurses are responsible for ensuring their
documentation is accurate, timely, and complete.
Security: Safeguarding client health information is paramount,
adhering to confidentiality and information retention policies.
Documentation must comply with legal and professional standards to
protect both the client and the healthcare provider.
Regular training and updates on documentation standards are
necessary to maintain compliance.
Methods of Documentation
Paper Documentation: Less common in modern practice, but still
used in some settings.
Electronic Documentation: Utilizes Electronic Health Records (EHR)
for improved information flow and accessibility.
Keys to Electronic Records: Interoperability, portability, and ease of
access are critical for effective EHR use.
Documentation Types: Includes narrative notes, S.O.A.P, D.A.R, focus
charting, flow sheets, and incident reports.
Importance of documenting everything: assessments, planning,
interventions, and outcomes.
Legal and Ethical Considerations in Documentation
Legal Aspects of Documenting
The phrase 'If it was not documented, it was not done' emphasizes the
legal importance of thorough documentation.
Nurses must be computer literate to effectively use electronic
documentation systems and communicate orders.
Documentation serves as a legal record of care provided and can be
scrutinized in legal cases or disciplinary hearings.
Ethical dilemmas may arise in documentation, requiring nurses to
navigate confidentiality and information sharing responsibly.
Understanding the legal implications of documentation is essential for
protecting both the patient and the nurse.
Ethical Principles in E-Documentation
Ethical dilemmas can occur when sensitive information is accessed
improperly, as illustrated in the case scenario involving Akira Sato, RN.
Nurses must consider principles such as confidentiality, informed
consent, and professional integrity when documenting.
Alternative responses to ethical dilemmas may include reporting the
breach of confidentiality or discussing the issue with a supervisor.
Regulatory standards guide nurses in maintaining ethical practices in
documentation and patient care.
Continuous education on ethical standards is necessary to navigate
complex situations in healthcare.
Documentation Strategies and Best Practices
Effective Documentation Strategies
Nurses should make notes of important findings and give themselves
adequate time to document accurately.
Drafting documentation before finalizing can help clarify thoughts and
ensure completeness.
Reviewing other nurses' documentation can provide insights into best
practices and improve one's own skills.
Directly quoting clients or family members enhances the accuracy and
authenticity of documentation.
Ending notations with interventions taken provides a clear picture of
the care provided.
Common Deficiencies in Documentation
Examples of deficiencies include vague descriptions of patient
conditions or failure to document interventions.
Regular group activities can help identify and correct deficiencies in
documentation practices.
Case studies can illustrate the consequences of poor documentation,
emphasizing the need for thoroughness.
Nurses should be trained to recognize and rectify common
documentation errors to improve patient care.
Continuous feedback and peer review can enhance documentation
quality across the nursing team.
Key People
Archana Paul: Associate Professor at York University, specializing in
nursing education and professional communication.
Key Regulations/Legislation
CNO Practice Standard: Documentation (Revised 2008): A
standard that outlines the expectations for nurses regarding
documentation practices, ensuring accuracy, clarity, and
confidentiality.
Key Methods of Documentation
Method Description
Narrative A descriptive method that includes detailed accounts of
Charting patient care.
A structured format: Subjective, Objective, Assessment,
S.O.A.P
Plan.
D.A.R A format focusing on Data, Action, Response.
Focus Charting Emphasizes specific patient problems or issues.
Flow Sheets Used for tracking patient data over time in a visual format.
A simple method to ensure all necessary information is
Checklists
documented.
Incident Documentation of unusual events or incidents affecting
Reports patient care.
Key Strategies for Documentation
Make a note of important findings: Capture significant
observations during patient care.
Draft first: Write a preliminary version before finalizing
documentation.
Review other nurses’ documentation: Learn from peers to improve
your own documentation skills.
Directly quote clients: Use the exact words of clients or family
members for accuracy.
End with interventions: Always conclude with how you addressed
the client’s needs.
Facts to Memorize
CNO Standards on Documentation: Communication, Accountability,
Security.
Key components of documentation: Assessment, Planning,
Interventions, Outcomes/Evaluations.
Common charting methods: S.O.A.P, D.A.R, Focus charting, Flow
sheets, Checklists.
Reference Information
CNO (2019). Practice Standard: Documentation, Revised 2008.
Importance of electronic health records (EHR) in improving information
flow and quality of care.
Problem-Solving Steps
1. Identify the purpose of documentation in nursing practice.
2. Understand the legal and professional standards guiding
documentation.
3. Choose the appropriate documentation method (e.g., narrative,
S.O.A.P, D.A.R).
4. Ensure accuracy and completeness in documenting assessments,
interventions, and outcomes.
5. Review and revise documentation for clarity and compliance with CNO
standards.
Key Terms/Concepts
Professional Communication: A complex interactive process used in
clinical settings to help individuals achieve health-related goals.
Documentation: The process of obtaining, organizing, and conveying
health information in print or electronic format to monitor client
progress and communicate with care providers.
Electronic Health Record (EHR): A digital version of a patient’s
paper chart that contains the medical and treatment history of the
patients.
CNO Standards on Documentation: Guidelines set by the College of
Nurses of Ontario that emphasize communication, accountability, and
security in nursing documentation.
