Documentation Components

The components included in a client’s record (and the names of these components) may vary between institutions and practice settings. A list of these components may include:

Admission sheet: This is one of the first items that you will see in the chart of a hospitalized client or in-patient client. It will vary between institutions, but generally includes information about the client including their name, age and date of birth, gender, contact information/address, admission date, reason for admission, and next of kin and/or emergency contacts. Importantly, the admission sheet identifies and highlights in red writing any known allergies. It may also include other health issues, list of current medications, personal items like dentures, glasses or assistive devices, a list of client valuables, and advance directives.

Progress notes or interdisciplinary notes: These refer to free-text entry space that allows for open-ended documentation. Many members of the interdisciplinary team may write notes in the same section of the client record, or there may be specific areas for physician notes or nursing notes. These notes will include a record of your assessment and care of the client including the client’s health status and/or responses to interventions. You will use specific documentation methods to organize these, as discussed later in this chapter.

Referrals and consultations: Here, healthcare providers document expertise about a client’s healthcare status/condition and advice related to the plan of care. The format is similar to that of progress notes.

Diagnostic, laboratory, and therapeutic orders: In these sections, healthcare providers provide orders related to diagnostic tests (e.g., ultrasound, X-ray orders), laboratory orders (e.g., blood, urine tests), or therapeutic orders (e.g., medications, diet, mobility orders). These are sometimes referred to as “physician orders” or “doctor orders.” Nurse practitioners can also provide some of these orders, depending on provincial and territorial body regulations and institutional policies.

Medication administration record: This is commonly referred to as the MAR, which includes a list of all medications that are ordered for the client: medication name, dose, route, frequency, date the medication was ordered, and the date it will expire. It also details any consideration for administration, such as a minimum apical heart rate before administration. Any client allergies are highlighted in red. As the nurse, you must document the date and time, and sign and initial the MAR, when you prepare and provide any medication. Some forms include a space for noting items such as the client’s apical pulse or temperature. Electronic MARs are particularly helpful by providing notifications: related to timing of medication to prevent missed doses, when a medication is about to expire, or when a new medication is ordered. Importantly, certain classes of drugs such narcotics require special documentation and witnessing protocols because of the potential for illicit use; consult your institutional policies for guidelines related to documenting narcotic dispensing, administration, and disposal.

Flow sheet and graphic record: These are commonly completed by nurses and include the documentation of physiological data like vital signs, pain, and weight. These records can also include routine documentation related to hygiene, mobility, nutrition, and the use of restraints. They allow healthcare providers to observe trends in data over time and recognize cues that require intervention.

Kardex or summary sheet: These forms summarize important information that should inform your daily care of the client and must be continually updated during each shift. When it is documented in written form, it may be completed in pencil because it requires frequent updating. However, it is important to note that it is not a legal document when written in pencil. Therefore, any relevant information included in the Kardex must also be captured in the client’s permanent health record. This kind of form includes information such as:

• A stamp on the top with the client’s name, hospital identification number, and date of birth.

• Treating physician, client’s age, preferred gender, and diagnoses.

• Allergies, resuscitation status, and required safety precautions.

• Emergency contact information.

• Medications.

• Therapeutic orders (e.g., turning, ambulation, mobility aids, diet, dressing changes).

• Tests and procedures.

• Hygiene (e.g., if and how often they can have a shower or bed bath).

• Dressing and wound care instructions.

Nursing care plan: This form includes nursing diagnoses and a plan of care based on specific goals.

Operative procedures: The physician uses this form to document the specific details of a procedure and any complications.

Consent forms, resuscitation forms, and healthcare directives: These include all completed consent forms for procedures, completed and signed resuscitation forms, and information about any healthcare directives such as a legal document in which the client provides power of attorney for personal or financial care.

Discharge plan and summaries: These generally include information about preparation and teaching related to discharge; they should be written in clear and non-medicalized language that the client can understand. They provide specific step-by-step instructions that the client should follow when they are discharged, and may include:

• Education about their condition or disease.

• A list of medication including the name, dose, route, and frequency as well as adverse effects to watch for.

• Guidance surrounding nutrition in terms of the client’s diet (i.e., what they should eat, how often, what they should avoid).

• Information about mobility and mobility aids, such as specific goals in terms of activity and exercise (amount and frequency), and information about aids such as crutches or a cane and how to use them.

• Access to resources in the community such as homecare, rehabilitation, and meal-delivery services.

• Information about when to seek healthcare if the client experiences specific symptoms, adverse effects, or complications, and appointments related to follow-up care.

• Finally, this form documents the date/time of discharge and how the client is getting home (e.g., transportation and whether they are accompanied by someone).

Critical incidents: You may be required to report and submit forms related to specific incidents. Regulation 965 of the Public Hospitals Act (1990) defines a critical incident as “any unintended event that occurs when a patient receives treatment in a hospital, (a) that results in death, or serious disability, injury or harm to the patient, and (b) does not result primarily from the patient’s underlying medical condition or from a known risk inherent in providing treatment.” You will need to inquire about your workplace policies concerning critical incident reporting. In Ontario, hospitals are “required to report all critical incidents related to medication / IV fluids” (Ontario Ministry of Health and Long Term Care, 2011). This type of reporting is important to ensure patient safety by clarifying how the incident occurred and inform changes in practice so that unsafe acts are less likely in the future (Canadian Nurses Protective Society, 2005).

Workload measurement: You may be required to complete this kind of documentation. There are many types of workload measurement systems including common ones such as GRASP or other systems developed in-house. They allow organizations and leaders to monitor client care needs (e.g., number of care hours required) and nurse staffing requirements (Hadley et al., 2004). They are often used for quality improvement, securing funding, and decision-making concerning allocation of nurses. When required, you will usually complete these at the end of each shift; they may involve electronic tracking of the amount time spent with each client performing tasks such as measuring vital signs, administering medications, caring for wounds, etc.

Activity: Check Your Understanding