Clinical Documentation

Transcription

1 Approved by: Chief Operating Officer; and Chief Medical Officer Clinical Documentation Corporate Policy & Procedures Manual Number: III-120 Date Approved January 4, 2018 Date Effective February 9, 2018 Next Review (3 years from Effective Date) February 2021 NOTE: The first appearance of terms in bold in the body of this document (except titles) are defined terms please refer to the Definitions section. Purpose To ensure that clinical documentation within Covenant Health's clinical record, a subset of the health record, supports health care providers in the delivery of highquality patient/resident/client 1 care, strengthening and fostering patient safety and promoting continuity of care. To provide reliable, consistent clinical documentation practices that promote and enable a quality health system that is accessible and sustainable. To outline fundamental clinical documentation processes affecting Covenant Health clinical records that must be followed by health care providers in all care settings regardless of documentation technology (i.e. paper-based or electronic). Policy Statement Covenant Health health-care providers shall maintain accurate and complete clinical records of interactions with patients and families. Documentation shall reflect an accurate, clear and comprehensive record of the patient's perspective regarding their health care needs, goals and preferences; the health care provider's communication, assessments, interventions; and the patient outcomes. Heath care providers shall adhere to documentation standards identified by professional college regulation and standards, provincial legislation, Covenant Health policy, and medical staff bylaws. Applicability This policy and procedure applies to all Covenant Health facilities, staff, medical staff, students and any other persons acting on behalf of Covenant Health. Responsibility Health care providers have legal, ethical, organizational and professional obligations (authority, responsibility, and accountability) related to the maintenance of clinical records. These obligations reflect the care that is provided, facilitate communication among caregivers, and comply with the Health Information Act (HIA), and Covenant Health bylaws, policies and procedures. 1 Hereafter, all references to 'patients' includes residents and clients.

2 III-120 Page 2 of 10 Guiding Principles Clinical documentation is vital to the provision of patient-centred quality and safe health service(s) across the continuum of care. The clinical record is a critical component of collaborative care, patient and family-focused service, quality assurance and organizational learning. Effective clinical documentation promotes the care of both individuals and populations, while contributing to the improvement of the health care system as a whole. Clinical records must be reliable and accurate to enable "One Person, One Record, One System". Clinical documentation shall: 1. Support the practice of patient and family-centered care by promoting respect and dignity, information sharing, patient participation, honouring choices, and collaboration in influencing how health services are provided. 2. Be accurate, complete, clear, concise, legible, timely and ordered to enable the health care provider to: a) record the patient's perspective on their health care needs, goals, and preferences; b) access the needed information to make informed clinical decisions; c) communicate with the patient and other health care providers; d) integrate information to evaluate the current health status of the patient; e) develop treatment goals and integrated plans of care in collaboration with the patient and other health care providers; and f) provide continuity across care settings. 3. Support evidence-informed decision making using collaborative practice approaches to care delivery that are sensitive to scopes of practice, regulation and professional practice standards; professional judgement; and individual circumstances. 4. Accommodate minimum data sets, standardized terminologies, and standardized tools that best support clinical processes and outcomes. 5. Support Covenant Health in protecting and securely managing information in its custody and control. 6. Meet regulatory, legal, and Covenant Health requirements regarding monitoring of health status, care effects, and outcomes of services provided to patients. Procedure Refer to "Guidelines for the Clinical Documentation Process" attached.

3 III-120 Page 3 of 10 Definitions Authorized person(s) means individuals providing services, or acting on behalf of Covenant Health, who have been granted access to information on a need to know basis, including employees, students, appointees, volunteers, individuals providing services under a contract or agency relationship, health services providers, or others as defined by the Health Information Act [Alberta]. Clinical documentation means the process by which health information is captured in the health record to reflect patient care and to facilitate communication between providers. Clinical documentation also fulfills regulatory, legal and Covenant Health requirements, in written or electronic format, regarding status, care, and services provided to patients. Clinical record means the collection of all health records documenting health services provided and tracking the interactions with and communications between health care providers and the individual receiving health services. Health care provider means any person who provides goods or services to a patient, inclusive of health care professionals, staff, students, volunteers and other persons acting on behalf of or in conjunction with Covenant Health. Health record means Covenant Health's legal record of the patient's demographic, diagnostic, treatment and care information. Health service means a service or actions performed for or with a patient to protect, promote or maintain health; to prevent illness; to diagnose, treat or rehabilitate; or to take care of the health needs of the ill, disabled, injured or dying. (Health Information Act [Alberta]). Most responsible health practitioner means the health practitioner who has responsibility and accountability for the specific treatment/procedure(s) provided to a patient and who is authorized by Covenant Health to perform the duties required to fulfill the delivery of such a treatment/procedure(s) within the scope of his/her practice. Related Documents Covenant Health Advance Care Planning Goals of Care Designation, #VII-B-350 Allergy and Adverse Drug Reaction Communication and Documentation, #VII-B-360 Consent Policy & Procedures suite of policies Independent Double Check, #VII-A-70 Information & Privacy suite of policies Medication Administration, #VII-A-50 Medication Orders, #VII-B-125 Prohibited Abbreviations, Symbols and Dose Designations, #VII-A-25 Records Management, #III-55 Responding to Adverse Events, Close Calls and Hazards, #III-45 References AHS Clinical Documentation and Clinical Documentation Processes Directives, effective August 10, Covenant Health Medical Staff Bylaws, Item 421

4 III-120 Page 4 of 10 AHS/University of Alberta Hospital Patient Care Policy #19.5, Interdisciplinary Documentation". Effective March 11, AHS/University of Alberta Hospital (2009) Nursing Documentation 19.6 College and Association of Registered Nurses of Alberta (CARNA), Online Education. "Your First Year in the Nursing Profession Documentation: Principles and Pitfalls. Accessed December 12, College and Association of Registered Nurses of Alberta (CARNA), Documentation Standards for Regulated Members, January 2013 College of Nurses of Ontario. Practice Standard 'Documentation' Accessed December 12, AHS Health Professional Strategy and Practice, Professional Practice Notice, dated Sept. 21, 2015, titled "What is the expectation for documenting signature and credentials for AHS recreation therapists?". Accessed December 12, Previous Versions Date(s) N/A

5 III-120 Page 5 of 10 GUIDELINES FOR THE CLINICAL DOCUMENTATION PROCESS 1. Authority to Document Health Information 1.1 Only authorized persons shall: a) Add health information to the clinical record for clinical documentation purposes; b) Add health information to the health record for administrative purposes (e.g. administrative health information such as appointment information kept outside of the clinical record; and registration information added as part of an administration function to the clinical record); and c) Transcribe documented health information to the health record (e.g. dictation / speech / transcription). 1.2 Adding health information to the clinical record includes any contribution of data, information, or records to an entry (e.g. entering or capturing data or information, attaching photos, and uploading documents). 2. Responsibility for Completing Clinical Documentation 2.1 The health care provider delivering the health service(s) shall complete clinical documentation in the clinical record unless: a) Professional standards specifically permit an alternate person to complete the documentation; or b) A situation described in section 2.2 applies. 2.2 In certain defined circumstances, an alternate health care provider (i.e. someone other than the health care provider delivering the health service) may be designated to enter health information on the clinical record. Such circumstances may include: a) When acting as a designated recorder (e.g. during a life-threatening event). The recorder documents the names of the health care providers involved, their role, all actions taken, and the patient's outcome or response. To end the process, the most responsible health practitioner must sign-off on the documentation as it contains orders for medications and procedures; and b) At the completion of a critical incident the documentation must be reviewed for accuracy by the clinical team members because they are responsible for the legal documentation regardless of who was the recorder.

6 III-120 Page 6 of 10 c) Where there is an imminent risk of harm to the patient if information is not added to the clinical record, and the health care provider who provided the health service is not available to add the health information to the clinical record within an appropriate amount of time given due consideration to the risk involved. 3. Authenticating a Clinical Documentation Entry 3.1 Clinical documentation must be authenticated by the health care provider who created the entry. a) When entering information in an electronic health record, follow the defined process for authentication in a clinical information system. b) When entering information on a paper-based health record, complete the Signature Identification Log (form #CH-0295). See points 3.2 and 3.3 below. 3.2 Signature logs must be maintained on each individual paper-based patient health record. Each admission requires a new signature log. Photocopied signature logs shall NOT be used. 3.3 All health care providers who document within the patient health record shall complete the Signature Identification Log by: i. printing their first and last name; ii. providing a signature; iii. providing their initials (as they would be shown on the record); and iv. providing their professional designation (regulated workers) or indicating their role (unregulated workers). Note: When holding more than one position/role, identify the role/job based on the qualification required for the role you are fulfilling at the time of the intervention/documentation 3.4 Co-signature or co-initials may be used where the meaning or purpose of the cosignatures or co-initials is clear Note: The act of co-signing a chart is appropriate only when providing direct supervision. Cosigning documentation indicates that you agree with the documentation, were present to verify the assessment findings and agree with the appropriateness of the intervention provided. If you co-sign notes, you must remember that simply reading a chart note is insufficient to satisfy your responsibility.

7 III-120 Page 7 of Timely Entry 4.1 Clinical documentation must: a) Be entered at the time of the event or as soon as possible thereafter; and b) Be completed by signing, or saving in the case of an electronic medical record. 4.2 An entry should never attempt to preserve the chronological order of the interaction/ intervention date and time by entering an artificial or inaccurate documentation date and time. 4.3 When clinical documentation is entered out of chronological order, it is a 'late entry' and shall identify: a) A notation that it is a 'late entry'; b) The documentation date and time; and c) The patient interaction/intervention date and time. 4.4 The frequency of entries in a clinical record depends on the situation and should reflect: a) The acuity of the patient's condition; b) The degree of risk associated with the procedure/treatment; and/or c) Any specific program and/or unit requirements. 4.5 In a computer downtime situation, applicable downtime procedures shall be followed and retrospective entries in the clinical record made accordingly. 5. Clinical Documentation Content 5.1 Clinical documentation shall: a) Be a complete record of health service(s) provided to the patient including the health care provider's observations, assessments, patient/family teaching, and communications, including discharge plans; b) Document consent as per Covenant Health Consent to Treatment policies/procedures

8 III-120 Page 8 of 10 c) Document observations and discussions objectively and respectfully, refraining from any characterizations, assumptions, or personal bias of the patient, family members, or other health care providers; d) Document each time the writer notifies another staff member (third party) about the patient's condition or status; i. name and position of person being notified ii. date and time notified iii. information relayed (description of what was reported to the staff member and his/her response/plan. iv. failed attempts to reach third party e) Document adverse events as per Covenant Health Policy #III-45, Responding to Adverse Events, Close Calls and Hazards; f) Clearly indicate who the information was collected from (e.g. patient, family member, other). If the source was another health care provider, indicate that person's full name and designation. g) Accurately and clearly, describe interactions and communications that occur during the provision of health services; h) Detail patient/family teaching. Entries should include: i. a brief description of the material taught ii. the methods used for teaching (e.g. written, visual, instructional aides, pamphlets, etc.) iii. the involvement of and the interaction between patient and family iv. validation or comprehension of learning instructions, (e.g. through teachback) v. contact resources given to patient and/or family. i) Document when the patient is transferred to another unit or facility for a procedure (record destination, mode of transport, current health status) or when the patient returns from pass or treatment from another unit or facility j) Where applicable, be entered in the appropriate structured data fields to improve patient safety; k) Justify, support and outline any health service provided, including any patient response and/or change in condition indicating the need for further or varied interventions; l) Be based on the needs and circumstances of a patient;

9 III-120 Page 9 of 10 m) Enable members of a collaborative health team accessing a shared medical record to make appropriate decisions, respecting continuity of care and the treatment needs of a patient; n) Reflect changes in patient condition or health services provided in a way that can be easily reviewed and interpreted over time and throughout the life of the patient; and o) Include any applicable assessment data, problem and/or diagnostic statements, plans of care and/or treatment, stated goals and/or desired outcomes, implementation plans and/or intervention(s), outcome evaluations, and any other statements regarding the details of a health service provided; 6. Revising Clinical Records 6.1 Any health care provider who notices an entry containing incorrect or incomplete information shall notify the health care provider who created the entry. 6.2 Additions, corrections, and deletions (collectively referred to as 'revisions') shall be made by the health care provider who created the entry, except in the circumstances detailed in section 2.2 apply. a) Damaged/contaminated records shall be put in a protective cover and remain part of the health record. 6.3 Revisions to a clinical record shall not remove or obscure previously recorded information such that the originally recorded information is no longer visible or retrievable. 6.4 Revisions shall, along with the amended information, clearly indicate the amending date, time, and identity of the individual making the change. 6.5 Removal of information from a completed record shall clearly indicate that the information should no longer be considered but the information must still be readable and retrievable (e.g. a single line drawn through the text or electronic information removed from current view but not deleted from the system). 7. Auditing 7.1 Auditing of clinical documentation shall be used to support, measure, and continuously improve the clinical documentation process. 7.2 Individual departments and programs are responsible to ensure an adequate program to establish and perform clinical documentation audits, as appropriate.

10 III-120 Page 10 of 10 Appendix A All entries Abbreviations Acronyms Blank Lines Date & Time Double Entries Flow Charts and/or Forms Late entry New page Patient Identification To be written legibly, in black ink, and in English. Do not use any prohibited abbreviations. Refer to Covenant Health policy #VII-A- 25, Prohibited Abbreviations, Symbols and Dose Designations. Abbreviations of any kind are discouraged. Avoid using acronyms. Their use can often be misinterpreted as meaning something completely different than how it was intended. If an acronym is encountered in a patient order, clarify the meaning with the prescriber. The writer shall indicate name using initials, and professional designation following their narrative entry and then draw a horizontal line through any remaining blank space in that row. When the space is greater than one row, either a horizontal line in each row or a diagonal stroke to encompass all rows shall be used. Identify date as day-month-year. For example, 02-Jun-2017 day will be two letters i.e. 02 month will be first three letters i.e. Jun year will be four numbers, i.e identify time in 2400 hour clock Refrain from entering the same information into separate documents, as this increases the risk of incorrect documentation between different sources. If something is written or documented in one location that specific information should not be repeated in another location. Option: The writer can state refer to, and name the source, e.g. vital signs record. Adhere to documentation guidelines as indicated on the specific form. When this type of documentation is referred to in the narrative record, refrain from identifying it as tick/tic charting. Instead, identify the document /form by its official title. When entries are not in chronological order, they are to be documented as a 'late entry'. When a late entry is required, the current date and time must be documented, followed by 'late entry' and the time and date for which the late entry relates. The reason for the late entry shall be documented. E.g. Late entry for 18- Apr-2017 at 09:30. Chart not available. Patient up in chair at side of bed, followed by health care provider initials and professional designation. Refer to section 4.2 in Guidelines. The health care provider shall document 'continued', provide initials and professional designation at the end of the completed page. The continuation of the entry on the second page shall include the date and identification that documentation is a continuation of previous page; this is the event of lost pages occurring. Every page on the health record will have patient identification (i.e. patient label), including the back of double-sided forms or on each screen of an electronic record.