175 7.4.1 Integrated Documentation

NPs working in LTC may be expected to document. Poor documentation practices in LTC:

• May contribute a delayed response to a change in health status
• May negatively affect a resident’s safety, health, and wellbeing
• May negatively affect patient health outcomes
• Contribute to critical incidents

The Medical Record may include:

• Advance Care Plan
• Medical history
• Medications
• NP/MD progress notes
• Progress notes by team
• Documented physical exams
• Care plans
• Consult notes from specialist
• Diagnostics – labs and imaging
• Admission and discharge summaries
• Resident Assessment Instrument (RAI) Assessments
• Comprehensive assessments

Effective documentation facilitates:

• Health care providers having the right patient health information at the right time to guide decision making
• High quality comprehensive care that is resident centered, holistic, and inclusive
• Continuity of care and safe transfers in care amongst rotating staff
• Effective individualized care plans
• Interdisciplinary team mobilization to effectively meet a resident’s needs
• Accurate data to facilitate quality RAI assessments
• Effective infection control practices

LTC National Standards: Individualized Care Plan

• Ongoing documentation of needs
• An accurate problem list that captures active issues and their treatment plans
• Residents’ goals of care, preferred level of medical information, needs, and preferences
• Team members involved in care
• Safety plans – risk for elopement, substance use, aggression

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