BCCNM LEARNING MODULE — WORKBOOK

Documentation
In Nursing Practice

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Introduction

Introduction
This workbook offers activities that allow you to apply ideas presented in the module. It is organized
in four sections:

Part 1 includes workbook activities that are related to various topic areas addressed in the learning mod-
ule. As you work through the module, you will be directed to complete a specific workbook activity. Part 1
also includes pages for you to record your thoughts related to learning in this module. There are two pages:
“Thoughts from Reflection Points” provides a space to jot down your thoughts related to “Reflection Points”
included in the Module, while “Insights and affirmations” provides a space to note new insights related to
your documentation practice. This information will be useful for you in completing your learning plan at the
completion of this module.

Part 2, “Applying My Learning”, includes case scenarios and associated questions. Completing the
questions related to the cases provides an opportunity for you to apply all of the information that has been
offered in the module in the context of practice-based scenarios. When you have completed the questions,
you may wish to compare your responses with those provided in the “Applying my learning:Perspectives”
located in Part 4.

Part 3 This section of the workbook provides an opportunity for you to create a plan for your professional
growth. A sample Learning Plan is provided to help you in this process.

Part 4 presents sample responses to Workbook Activity # 4 and to the case scenarios included in Part 2:
“Applying My Learning.”

Documentation in nursing practice workbook |1

PART 1

Workbook Activities
 1 Workbook Activity #1

This activity provides an opportunity to explore the purposes of documentation and how effectively
your current documentation practices support these.

1. First, select an example of your ‘everyday’ nursing documentation. There are several ways you can do
this. You may wish to think back over your last day at work, recall a specific client situation and, as far
as possible, recall what you documented related to that situation. Alternatively, you could imagine a
‘typical’ client situation in your workday and create ‘typical’ documentation for that situation. Or, you
may wish to bring an example of your documentation from you next day at work, and use it to com-
plete this activity. Regardless of the source, describe that documentation now in the space below.

2. Now, consider your documentation example and note down your thoughts related to the following
questions:
• How effectively did you communicate information for other health care professionals?
• Does the information you recorded (and the way you recorded it) support the goal of provision of
safe, appropriate client care by all health care professionals?
• Does your documentation provide evidence that your practice is congruent with BCCNM Standards
for Practice?
• In the event of some legal proceeding, would your documentation provide sufficient evidence of
care provided such that it is understandable several years from now?

3. What have you learned about your documentation processes in this activity? Note your thoughts
here so that you can come back to them later.

Documentation in nursing practice workbook |3

 2 Workbook Activity #2

This activity provides an opportunity for you to consider the interrelationships between your docu-
mentation, various directing and influencing factors and client outcomes.

1. Return to the client situation and related documentation that you recorded in Workbook Activity #
1. Using the conceptual map of documentation included in the module, explore your documentation
processes and content in this situation.
• What factors provided the most direction for your decision to document and the nature of what
you documented? Was it legal considerations? Professional requirements? Personal knowl-
edge, judgments, and ethical perspectives?
• What did you document? Is the client’s perspective or experience reflected? Did you include
assessment data,as well as your actions? Did you include evaluation and client outcomes? If
not, why are these not part of your documentation?
• If the situation involved interactions with other health care professionals, is that evident in your
documentation?
• Does your documentation support you and other health care professionals in providing safe,
appropriate and ethical client care?

2. Now take a few moments to reflect on this section of the module and Workbook Activity # 1 and #2.
What have you learned about your documentation processes in your nursing practice? Were aspects
of your documentation processes affirmed by this discussion and workbook activity? Or perhaps you
have experienced some new insights regarding the extent to which your documentation fulfills the
purposes of documentation in provision of safe, appropriate and ethical client care?

Record these conclusions on the “Affirmations and Insights” page of this Workbook. At the comple-
tion of the module, you will have an opportunity to use the insights and affirmations gained in various
learning activities, as part of your planning for future professional growth and development.

Documentation in nursing practice workbook |4

 3 Workbook Activity #3

In this activity you will explore the direction provided within BCCNM regulatory documents for your
documentation processes in nursing practice. The documents can be accessed by links in the learn-
ing module or directly from www.bccnm.ca.

1. Begin by reviewing the BCCNM Professional Standards for Registered Nurses and Nurse Practitioners.
As you review the standards and associated indicators, consider how they relate to your documen-
tation processes. In what ways do the standards and indicators provide direction for competency
related to documentation in nursing practice?

When you have completed this activity, you may wish to compare your conclusions with informa-
tion provided in the BCCNM Practice Support Guidelines for Documentation, p. 8 and 9.

2. Now, please review the BCCNM Practice Standard for Documentation. As you read the Practice
Standard, reflecton the principles and the direction they provide for your documentation processes
in your nursing practice. Does your documentation reflect these principles? Do the principles offer
insights or solutions for areas of documentation that you are unsure about or find challenging? Keep
in mind, you will have an opportunity to explore these principles further in the section of this module
that focuses on characteristics of effective documentation.

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 4 Workbook Activity #4

This activity provides an opportunity for you to explore the characteristics of effective documenta-
tion by examining three short scenarios.

SCENARIO #1
Mr. Ron Brown is a 71-year-old gentleman with Type 1 diabetes admitted to hospital for treatment of an ulcer
on his right heel. Diane was assigned to Mr. Brown and Diane also provided nursing care to him yesterday.
Mr. Brown was alert and oriented to person, place and time. He normally had no problems with ambulation.
Mr. Brown wears glasses to read and drive and he has no hearing deficits. He lives alone. Mr. Brown’s dis-
charge plan is to return to his apartment.

During her morning assessment, Diane noted at 0800 that Mr. Brown had some facial grimacing and he
limped on his right foot when he walked to the bathroom. When asked, Mr. Brown tells Diane “I have pain
where the ulcer is”. Diane probed further to determine the characteristics of Mr. Browns’ pain as constant
and throbbing, and he rated it’s intensity as 6 out of 10. Diane administered pain medication (Tylenol #3- 2
tablets) at 0830. Diane reassessed Mr. Brown’s pain at 0945 and he rated the intensity at 1 out of 10.

Diane decided to do Mr. Brown’s dressing change at 0950 since Mr. Brown’s pain was controlled. When
Diane removed the old dressing Diane noted a moderate amount of fresh watery, bloody drainage with a
small amount of green-yellow pus drainage. The ulcer area was round and the size was about 3 cm x 4 cm,
the area around the ulcer was red. The ulcer borders were well defined. Most of the wound bed was granu-
lation tissue with a smaller amount of yellow slough. Mr. Brown had decreased sensation to this area of his
foot as he could not feel the coolness of the solution or feel when Diane was pressing down. An adaptive
dressing, 2- 4x4 gauze and ½ abdominal pad were placed on the wound. Mr. Brown did not complain of any
discomfort during the dressing change. Diane entered the following documentation in Mr. Brown’s record:

815 Client reports pain right foot. Diane Smith, R.N.

830 Tylenol #3 two tabs given for complaints of pain. Diane Smith, R.N.

950 Dressing to right foot changed for moderate amount of bloody drainage Diane Smith, R.N.
with some pus. Wound looks clean and healing. Client tolerated dressing
change well.

1. Critique Diane’s documentation on the care she provided to Mr. Brown. Identify what she did well, and
the areas where she could improve her documentation using the characteristics of effective docu-
mentation in this section as a resource.

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 4 Workbook Activity #4 con’t

2. Imagine you are Diane. Document the care you provided to Mr. Brown correctly in the space below.

SCENARIO #2
Mrs. Ada Green, an 89-year-old widow, lives alone in her two story home. She is recovering from surgeryfol-
lowing an “anterior resection” for bowel carcinoma. She was discharged with a Home Nursing Care referral
for a home transition assessment and wound healing assessment because she developed a post surgical
wound infection while she was in hospital. At discharge from hospital Mrs. Green was alert and determined
to remain independently mobile in her own home for as long as possible. Mrs. Green has Meals on Wheels
delivered twice weekly and private home support twice weekly for assistance with personal care. She is on
a regular diet and is capable of managing her cardiac, pain and antibiotic medications, which her friend has
labelled for her. A neighbour assists with transportation, shopping and social planning. Mrs Green has no
family in town.

On the morning of October 12 at 0950, three days after being discharged from hospital, Janie, the Home
Care Nurse, found Mrs Green sitting in her chair looking anxious and somewhat unkempt. She was rocking
back and forth, clutching her abdomen and moaning. When asked she stated “I’m in pain” and “ I can’t seem
to catch my breath”. Her dressings were in disarray, there was a distinct fecal odour, and she was diapho-
retic. She admitted that she had spent the night in her rocker, did not know the time and could not recall
when she had last taken her pills or eaten. Janie took her vital signs and they were as follows: Temperature:
38 degrees Celsius, pulse 110/minute and regular, blood pressure 100/70 mmHg, respirations 28 breaths/
minute and mildly laboured.

1. Imagine you are Janie. Document your assessment of Mrs. Green to this point in the space below.

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 4 Workbook Activity #4 con’t

SCENARIO #3
Jim, a nurse in the intensive care unit of a tertiary hospital is beginning a busy day with his assigned patient.
Alex, another nurse on the unit offers to help Jim out. Jim tells Alex that it would be a great help if he could
give Mr. White 2 mg. of morphine IV now as Mr. White indicated that he had some pain when Jim assessed
him just 10 minutes ago. Jim had not yet had time to administer analgesic to Mr. White.

Alex checks the order, asks Jim a few more questions about Mr. White, then heads off to get the morphine
from the narcotic cupboard. He returns and administers the Morphine to Mr. White.

1. Suggest appropriate documentation for this scenario.

2. What other follow up care and documentation would be required in this situation?

Now take a few moments to reflect on this activity. What have you learned about your documenta-
tion processes in your nursing practice? Were aspects of your documentation processes affirmed by
this workbook activity? Or did you experience some new insights regarding your documentation?
Record these conclusions on the “Affirmations and Insights” page of this Workbook. At the com-
pletion of the module, you will have an opportunity to use the insights and affirmations gained in
various learning activities, as part of your planning for future professional growth and development.

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 5 Workbook Activity #5

This workbook activity is a self-assessment of your documentation practices. For this activity, you’ll
complete a self-assessment checklist based on the BCCNM Principles of Documentation, the char-
acteristics of effective documentation and your understanding of documentation approaches. By
completing this checklist, you’ll be identifying your personal strengths in documentation practice
and also areas where you need to further develop your documentation practice.

SELF ASSESSMENT I WANT TO IMPROVE MY NOTES

PRACTICE IN THIS AREA
YES NO

Regardless of documentation approach, I

always document all clinically significant
information using the nursing process
(assessment, nursing diagnosis, planning,
intervention and evaluation) on the client’s
health record. This includes information
or concerns reported to another health care
provider and, when appropriate, that provider’s
response.

I document the care I personally provide to

the client.

I do not document routine care that other

health care providers provide a client.

I know in which emergency situations I may

document care another health care provider
provides.

My documentation is clear, concise, factu-

al, objective. My documentation contains
significant details and accurate descriptions.
I avoid generalizations and I avoid vague de-
scriptors and subjective judgments. I identify
any client comments.

I use only approved abbreviations.

My documentation is chronological and timely.

When I am unable to document in a timely

or chronological way, I mark “late entries,”
recording both the date and time of the late
entry and of the actual event.

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 5 Workbook Activity #5 con’t

Self Assessment I want to improve my Notes

practice in this area
YES NO

I add my signature and title, or initials as

appropriate, to each entry they make on the
health record.

I document legibly.

I document comprehensively, in-depth and

more frequently when clients are acutely ill,
high risk or have complex health problems.

I document care/services provided to a

group and overall observations pertaining to
the group on the appropriate forms. I doc-
ument information about individuals in the
group on their personal health records.

I have read and understood the documen-

tation policies of the agency and unit where
I work. I document using the tools and
method(s) supported by the agency and unit.

I use documentation tools appropriately,

knowing which tools becomes part of the
client’s health record and which do not. I
ensure all necessary information about the
client is documented on the client’s health
record.

I maintain the confidentiality of a client’s infor-

mation and client record.

I only access a client record when I have a

professional need.

For nurses who have responsibility for client

records: I retain the client’s record for a
minimum of six years after the client is last
assessed or treated. If the client is a minor, I
retain the record for six years after the client
reaches age 19.

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 6 Workbook Activity #6

In this activity you will use the information presented in the section related to errors in nursing
documentation to explore your own documentation practices, including planning strategies that will
minimize future errors.

1. Take a few moments to review your responses to the reflection points in the section you have just
completed.
Based on your insights, select 2-3 errors that you have become aware of within your own documenta-
tion practices. Note them on the following table.

2. For each of these errors, complete remaining columns in the table.

• Begin by considering why this error might be occurring. Did you not understand what was
required for acceptable documentation? Or are there other factors that influence what you
document?
• Now consider what concerns you have about this error? Are there legal implications? Or is there
a potential negative impact of client care?
• Finally, what strategies could you put in place that would support you in completing effective
and appropriate documentation?
An example has been provided to get you started.

Error in I am concerned Reasons that this Strategies that I can

documentation about this error error occurs in my use to avoid this error in
practice because . . . documentation my documentation

Briefly describe What are the Note down all reasons or Select strategies that will minimize or
error here legal or client factors that make it chal- negate the reasons/ factors that are
related implica- lenging for you to complete associated with this error.
tions associated accurate documentation.
with this error?

Leaving space for This is not No time to document as- 1. Could document that I have com-
my initial assess- acceptable legal sessment when I do it: pleted assessment when I do it,
ment & docu- practice: it expos- • Need to assess all 6 then can begin documenting other
menting other es me to the risk patients as soon as pos- care/ events as required. Docu-
events after that of being accused sible at the beginning of ment actual assessment findings
space. Returning of falsifying doc- the shift. as late entry, with appropriate
3 hours later to umentation. • Need to get 0800 or notation.
document my Documenting 2000 medications done 2. Explore with nurse manager the
assessment. three hours after as soon as possible. possibility of creating a ‘checklist’
an event increas- • Need to go to coffee assessment form that is com-
es the risk of break and/or do break pleted separately from narrative
error. relief according to unit documentation of events/ongoing
timelines. care.

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 6 Workbook Activity #6 con’t

Error in I am concerned Reasons that this Strategies that I can

documentation about this error error occurs in my use to avoid this error in
practice because . . . documentation my documentation

Briefly describe error What are the legal or Note down all reasons Select strategies that
here client related implica- or factors that make it will minimize or negate
tions associated with challenging for you to the reasons/ factors
this error? complete accurate docu- that are associated with
mentation. this error.

Documentation in nursing practice workbook | 12

 7 Workbook Activity #7

Documentation in Nursing Practice: Planning for Professional Growth

This final learning activity will guide you in developing a plan for future development of your documen-
tation in your nursing practice. Please see Part 3 in the Workbook for a plan outline and an example.

1. Begin by reviewing “Affirmations and Insights” insights page in this Workbook. This page includes all the
conclusions you have formed about your documentation in your nursing practice as you have worked
through this module. It is, in other words, a comprehensive self-assessment of all the components that
are part of, or influence, your communication. Now it’s time to put that to use!

Take some time to read through these conclusions: First, notice and acknowledge your strengths. Then
pay attention to the areas that you have identified as areas for development and growth. As you read
these, notice which ones seem to resonate with you or feel most important to you. Use these conclusions
to determine the goals that will support ongoing growth of your documentation skills and abilities.

2. Create three goals that reflect your focus for development in your communication. Write these in the
appropriate place in “My plan for growth in communication”.

3. The next step is to develop an action plan that will help you meet those goals. Begin by identifying
resources that you could use to assist you in meeting your goals. If you are not aware of specific re-
sources, then begin by listing the sources you will explore in order to learn what you can do to support
your growth toward your goals.

4. Once you are familiar with the learning opportunities that are available to you, create an action plan that
outlines specific strategies you will use, what resources you need in order to implement these strate-
gies (e.g. who do you need to talk to, learning materials you want to acquire, learning experiences you
need to arrange etc) and, importantly, a target date for completion.

Not sure how to do identify goals and create an action plan? The planning for growth page (in Part 3)
has provided a brief example of this process.

5. Finally: Add your plan to your Quality Assurance file, workbook or portfolio. And remember to update it
once you have completed the actions!

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 Notes from Reflection Points

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 My Documentation in Nursing Practice

Affirmations and Insights

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PART 2

Applying My Learning
 Applying My Learning

Case scenario one — Melanie

Melanie looked up at the clock — 11 a.m. “Wow,” she thought, “It’s been a busy day and I am not even
halfway through yet!” After 5 years in this extended care unit, she had got used to being busy, but today
seemed to be ‘one of those days’. She was, as usual, the only RN on today in this 36-bed unit, along with
one LPN and four registered care aides. She knew that everyone would be busy: The unit was full and the
current client group required a lot of care — and that made for a heavy workload for everyone.

She paused for a moment to collect her thoughts and decide on the next thing she needed to do. While her
responsibility encompassed all of the clients on the unit, there were four clients that particularly concerned
her today. Two were confused and agitated and required close monitoring, another was dying and, with his
family at his bedside, needed comfort care and support, and finally Mr Bell had been short of breath and
coughing during the night. When Melanie had looked in on him earlier he was breathing at 24/minute, occa-
sionally coughed up yellowish secretions and had a temperature of 37.6˚ C.

Her thoughts were interrupted when Jasmine, an LPN who had worked on the unit for 10 years, stopped
beside her and said, “Can you come and look at Mr. Bell? He seems to be worse that he was earlier this
morning. I sat him up a bit more and that helped a little, but I am quite concerned about him.” Melanie nod-
ded and they walked down the hallway to Mr. Bell’s room. At first glance it was clear to Melanie that he was
worse. His face was slightly diaphoretic and she could hear his coarse cough. When she asked him how he
was feeling, he replied, “I feel pretty tired. This coughing is wearing me out.”

She nodded and said, “I can see that. If it’s OK with you, I would like to have a closer look at you.” She count-
ed his respiratory rate at 26/minute and then had a quick listen to his chest. She noted that he had coarse
crackles in both posterior and anterior lower lung fields. His temperature was 37.7˚ C.

Melanie bent slightly closer to him and spoke gently. “Mr. Bell, I can see that you are not feeling well and
that you are tired. Your chest sounds kind of rattly and you have a bit of a fever. I am going to call your family
doctor and let him know. I’ll come back as soon as I have done that and let you know what he says.”

Melanie called Dr Simms and explained the situation, outlining the change in Mr. Bell’s condition over the
previous 24 hours. In response, Dr Simms suggested that Mr. Bell “probably has the flu that’s going around”
and instructed Melanie to “keep an eye on him” and to “call him back if she was concerned”.

Melanie hung up the phone and pulled Mr. Bell’s chart from the shelf. She made the following entry in his
nursing notes:
“Client seems short of breath. Has a fever. Doctor informed.”

Melanie returned to Mr Bell and, as per the unit’s standing orders, gave him some Tylenol elixir “for com-
fort”. She also made sure he was well positioned in bed and then left the room to continue with her care for

Documentation in nursing practice workbook | 17

 Applying My Learning

Case scenario one — Melanie con’t

other clients. Over the next four hours, she checked in on Mr Bell several times and counted his respiratory
rate, noting that it was still high. At one point she listened to his chest again, noticing that the crackles had
increased. Four hours after her initial phone call, Melanie was quite concerned about Mr Bell – His respira-
tory rate was 30/minute, he seemed to be working harder with his breathing, his chest sounded worse, and
his pulse oximeter read 92%. She knew that often when clients were sick like this, that they would be send
the client to ER at the local hospital, however, Dr Simms had indicated he was happy to be called about his
clients, so she decided to call him again and update him. After she had explained the situation, Dr Simms
said, “I am leaving my office shortly and have to drive past the care facility on my way home, so I will drop in
and have a look at Mr Bell.”

Melanie reached hung up the phone, glanced at the clock and realized she has several medications that she
was late dispensing. She quickly wrote a note in Mr Bell’s chart, and then left the office area to attend to the
medications.

Client’s breathing looks worse. Doctor notified.

Dr Simms arrived 45 minutes later and assessed Mr Bell. He then wrote an order to start Mr. Bell on antibi-
otics and to begin supplemental oxygen via nasal prongs at 3L/minute. Melanie came into the office as he
had just completed writing the orders. “Oh Hi, you’re here,” she said. “What do you think is happening?” she
asked.

He replied, “I think he has the flu, and seems to have a bit of chest infection. I have ordered him some anti-
biotics and we can start some oxygen therapy and see if that makes him more comfortable. Can you check
his pulse oximeter readings every two hours. If they fall below 92%, or if you think he is getting worse,
please call an ambulance and send him to the ER.”

As Dr Simms left, Melanie reviewed the orders he had written and faxed the prescription for antibiotics to
the pharmacy. She also updated the documentation in Mr Bell’s chart:

Dr in. Orders received.

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 1 Case Study Activity #1

CASE SCENARIO ONE — MELANIE

Please answer the following questions. When you have completed this activity, you may wish to
compare your responses with those provided in the “Perspectives” section at the end of this workbook.

1. Review Melanie’s documentation. In what ways does it meet criteria for effective documentation?
What documentation errors are present? Where there are errors, describe how Melanie should have
documented Mr. Bell’s care in these situations. Provide examples of effective documentation.

2. What factors do you think influenced Melanie’s ability to document appropriately in this situation?
What do you think could be done that would assist Melanie to document effectively in future?

3. What are the implications of Melanie’s ineffective documentation for Mr Bell’s outcomes?

4. Consider the conceptual framework and directives for documentation in nursing practice. What could
be the implications of Melanie’s ineffective documentation for herself?

Documentation in nursing practice workbook | 19

 Applying My Learning

Case scenario two — Rick

Rick Ross, RN, hung up the telephone in the Emergency Department (ED) of Elsewhere General, a 30-bed
rural hospital in northern British Columbia. Rick had worked at Elsewhere for three years now since grad-
uating . . . two of those years had been on the combined medical-surgical ward, and one year as a critical
care/ ED float nurse. Rick was working in the locked ED late this particular evening. The other critical care
educated nurse in the hospital, Janet, had primary responsibility for two patients in the 3-bed close obser-
vation unit located between the med-surg ward and the ED.

There were no patients in the ED, but that would soon change: the paramedics were on their way with Mr.
Hugo Stivic, a 58-year-old man who was experiencing chest pain. Mr. Stivic, the paramedics said, was short
of breath, wearing oxygen, and had been given aspirin and three sprays of Nitrospray. Rick looked thought-
ful as he picked up the phone again to call Janet. After hearing Rick’s message, Janet said she would give
report to the ward nurses and be down to help Rick with Mr. Sticvic’s admission. Rick made one more phone
call to the physician on call who, after hearing Rick’s report, said she’d be to the ED within 15 minutes. She
reminded Rick to institute the hospital’s ‘chest pain protocol’.

By the time Mr. Stivic came through the doors of the ED, Janet had arrived to help Rick. Rick asked Janet if
she would draw up some morphine and prepare a nitroglycerin infusion while he assessed Mr. Stivic. Rick
took Mr. Stivic’s vital signs, noting them on his ‘cheat sheet’, and asked Mr. Stivic about his pain:
• ‘what would he rate his pain on a scale of 1–10 with 10 being the worst pain he had ever experi-
enced?’ . . . a 7 out of ten
• ‘had his pain decreased with the nitrospray?’. . . it had gone from 10 to 7
• ‘could he describe his pain?’ . . . it was a crushing pain in the middle of his chest that was making
it difficult to breathe • ‘did his pain radiate anywhere?’…down his left arm and up into his jaw
• ‘were there other symptoms?’ . . . yes, he was short of breath, diaphoretic and couldn’t breathe
• ‘when did it start?’ just after dinner time a little over an hour ago

Rick fumbled through the pile of papers that would become Mr. Stivic’s chart. Finding the ED admission re-
cord, Rick documented his pain assessment like this : “1920 hours: Patient arrived in ED experiencing severe
chest pain.”

Janet arrived back at the bedside just as Rick was obtaining blood samples from Mr. Stivic. Janet adminis-
tered 2 milligrams of morphine IV to Mr. Stivic in the intravenous initiated by the paramedics, and she hand-
ed the mixed bag of nitroglycerin to Rick who proceeded to hang it and commence the infusion at 20 mcg/
min. While Rick was busy, Janet went to get the ED’s 12 lead ECG machine, returned, and ran a 12 lead on Mr.
Stivic. Rick reassessed Mr. Stivic’s chest pain: he reported that it was now 5/10. Just then, Dr. Sinclair arrived
in the ED at Mr. Stivic’s bedside. She looked at Mr. Stivic’s 12 lead, asked him a few more questions about the

Documentation in nursing practice workbook | 20

 Applying My Learning

Case scenario two — Rick con’t

quality and timing of his chest pain, and told Rick to increase Mr. Stivic’s nitroglycerin infusion to 30 mcg/min
(which Rick did). She then told Rick and Mr. Stivic that she was going to arrange transfer by air ambulance to a
hospital where Mr. Stivic could have a procedure called a Percuatneous Transluminal Coronary Angioplasty.

At 1940 Rick assessed Mr. Stivic’s chest pain again as Jan prepared him for transfer, Rick returned to the ED
record to document the care provided. Here is a copy of the pertinent portion of the ED record:

Time Nurse’s notes Signature

1920. Patient arrived in ED experiencing severe chest pain RR, R.N.

1924 Bloodwork drawn RR, R.N.

1925 Morphine 2 mg IV given for chest pain. RR, R.N.

1926 Nitroglyceryn infusion commenced at 20 mcg/min. RR, R.N.

1930 12 lead ECG obtained. Dr. Sinclair arrived. RR, R.N.

1935 Nitroglyceryn infusion increased to 30 mcg/min. RR, R.N.

1940 Patient prepared for transfer to tertiary facility RR, R.N.

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 2 Case Study Activity #2

CASE SCENARIO 2 — RICK

Please answer the following questions. When you have completed this activity, you may wish to
compare your responses with those provided in the “Perspectives” section at the end of this work-
book.

1. Consider the characteristics of effective documentation. Identify 3 documentation errors in this sce-
nario. How should Rick have documented Mr. Stivic’s care in these situations. Provide examples.

2. What factors do you think influenced Rick’s ability to document appropriately in this case? What do
you think could be done to support Rick to document effectively in future.

3. What might be the implications of Rick’s ineffective documentation on Mr. Stivic’s outcomes?

4. Consider the conceptual framework and directives for documentation in nursing practice. What could
be the implications of ineffective documentation for Rick?

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PART 3

Growth Planning
 My Plan for Growth in Documentation

Goals
1.

2.

3.

Action plan
People or places that I can investigate for learning strategies to help me meet my goals for growth
are:

1.

2.

3.

Specific strategies that will help me in meeting my goals are:

Strategy Resources I need to Target Other thoughts

implement this completion
date

Reminder: Add your completed action plan to your Quality Assurance Portfolio.

Documentation in nursing practice workbook | 24

 My Plan for Growth in Documentation

An example
GOALS

1. To become familiar with best practices related to electronic documentation.

2.

3.

Documentation in nursing practice workbook page 25

ACTION PLAN

People or places that I can investigate for learning strategies to help me meet my goals for growth are:

1. Talk to Clinical Nurse Educator and/or Nurse Leader on unit for suggestions about learning resources.

2.

3.

Specific strategies that will help me in meeting my goals are:

Strategy Resources I need to Target Other thoughts

implement this completion
date

Example: detailed plan 1. None – just look on the 1. During my next

1. Review resources available in shelves & on the Intranet at set of scheduled
my nursing unit. shifts
work!

2. Review BCCNM resources 2. Use work or home com- 2. By end of this

regarding electronic documen- puter to do this. Website month
tation. URLs in Learning resource
section of module.

3. Complete Literature search 3. Call BCCNM library for 3. By end of next Could ask the nurse
using CINAHL advice & assistance in doing month educator at work;
this.. maybe she can help
me with this?

Reminder: Add your completed action plan to your Quality Assurance Portfolio.

Documentation in nursing practice workbook | 25

PART 4

Workbook Activities
and Case Perspectives
 4 Workbook Activity #4

Scenario #1
1. Critique Diane’s documentation on the care she provided to Mr. Brown. Identify what she did well, and
the areas where she could improve her documentation using the characteristics of effective docu-
mentation in this section as a resource.

a. Diane did sign each entry correctly, and she documented in a timely and chronological manner

b. Diane did not include objective data about her pain assessment nor did she include all of the
objective data about the condition of Mr. Brown’s ulcer or his lack of sensation during the dress-
ing change.

c. Diane used some vague subjective expressions: ‘clean and healing’ and ‘tolerated well’
doesn’t convey the details and accuracy of Diane’s assessment and evaluation of care.

d. Diane did not document the effect of the analgesic she administered to Mr. Brown.
e. Anything else?

2. Imagine you are Diane. Document the care you provided to Mr. Brown correctly in the space below.

Here’s an example:

Time Nurse’s notes Signature

0800 Client limping on right foot and grimacing. When asked stated Diane Smith, R.N.
“ have pain where the ulcer is”. Client rated the intensity of
pain as 6 out of 10.

0830 Tylenol #3 two tabs given for complaints of pain Client reas- Diane Smith, R.N.
sessed.

0945 Client now rates intensity of pain as 1 out of 10. Diane Smith, R.N.

0950. Dressing removed from right heel ulcer for moderate amount Diane Smith, R.N.
of fresh watery, bloody drainage with a small amount of
green-yellow pus. Ulcer is 3 cm x 4 cm, boarders are well
defined with redness noted in surrounding skin.Ulcer bed is
granulation tissue with a smaller amount of yellow slough.
When asked, patient stated he could not feel pressure applied
to the area surrounding the ulcer and could not feel the cool-
ness of the dressing solution. Ulcer redressed with adaptive
dressing, 2 – 4x4 gauze and 1/2 abdominal pad. Client did not
complain of pain during procedure..

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 4 Workbook Activity #4 con’t

Scenario #2
1. Imagine you are Janie. Document your assessment of Mrs. Green to this point in the space below.

Here’s one example:

0950 — found client sitting in rocking chair clutching her abdomen, rocking and moaning. A dis-
tinct fecal odour is present around client. Client states she spent the night in her rocking chair.
Abdominal dressing no longer intact. Client stated: “I’m in pain” and “ I can’t seem to catch my
breath”. Client not oriented to time of day and cannot recall when she took her pills of ate last.
Vital signs as follows: 38˚ Celsius, pulse 110 and regular, Blood pressure 100/70 mmhg, respira-
tions 28 breaths per minute and client is diaphoretic and using accessory muscles to breathe.

Scenario #3

1. Suggest appropriate documentation for this scenario.

Jim should document his assessment. Alex should document the administration of the Morphine.

2. What follow up care and documentation would be required?

Jim should reassess his patient to ascertain if the analgesic was effective, then document this evaluation.

Documentation in nursing practice workbook | 28

 1 Applying My Learning

Perspectives
CASE STUDY SCENARIO 1: MELANIE
Review Melanie’s documentation: In what ways does it meet criteria for effective documentation?
What documentation errors are present? Where there are errors, describe how Melanie should have
documented Mr. Bell’s care in these situations. Provide examples of effective documentation.

In general, Melanie’s documentation addresses the ‘when’ aspects of effective documentation. In spite
of her busy day, Melanie documented in Mr. Bell’s chart when she noted a change in his condition and/or
when she interacted with the physician. In addition, she did this at the time of the event. These actions both
fulfill requirements for timely documentation. The frequency of Melanie’s documentation also reflects the
increase in Mr Bell’s acuity level. She documented three entries in the space of about 6 hours.

Now let’s look more closely at what Melanie documented. Each entry is very brief. While concise documen-
tation (how) is desirable, it is important that conciseness be balanced with providing adequate information.
In fact, Melanie has omitted important information in her documentation and so the documentation is incomplete:
• In entry #1 and #2, she has not fully documented Mr Bell’s condition or her actions.
• In entry #1, 2, & 3, she has not documented the content of her communication with Dr Simms,
simply noting that she has called him.
• Melanie has not documented any information related to her ongoing assessment of Mr. Bell
that occurred between the first and second entries.

A second concern related to Melanie’s documentation is that her descriptions of Mr. Bell’s condition are not
factual or objective. (She states he “seems short of breath” and ‘breathing looks worse”).

Here are some suggestions about how Melanie’s documentation could be improved in these situations. It
is possible that your examples of more effective documentation may look somewhat different to this one.
Using these examples as a guide, determine if your suggested changes have addressed the issues we have
identified.

Entry # 1:
Client’s face is pale and slightly diaphoretic. Respiratory rate is 26/min, with use of acces-
sory muscles noted (shoulders). On anterior and posterior auscultation, breath sounds are
clear in upper lung fields, with coarse crackles in lower lung fields bilaterally. Client states
he ‘feels pretty tired’. Coughing occasionally, productive for small amounts of yellow
tinged sputum. Temp: 37.7˚ C orally. Pulse rate 85/min. Blood pressure: 125/68. Dr Simms
notified of client’s current condition and changes over night.
Dr advised ongoing observation. Tylenol elixir 650mg given as per unit protocol.

Documentation in nursing practice workbook | 29

 1 Applying My Learning con’t

Perspectives
CASE STUDY SCENARIO 1: MELANIE
Missing entries — documented at time of care

Ongoing assessment should provide updates on previously noted concerns, and add any new information.
For example: Client’s respiratory rate remains at 28/min; work of breathing unchanged. Continues to expec-
torate small amounts of sputum.

Entry # 2: (at hour 4)

Client’s face diaphoretic; Respiratory rate 30/min. Use of accessory muscles (shoulders)
noted. On auscultation: coarse crackles audible in right lower and mid lung field, as well as
left lower lung field. Client states “he is really tired.” Coughing more frequently for small
amounts of yellowish sputum. Temp 37.2˚ C, pulse 92/minute. Blood pressure: 145/75. SpO2
92%. Dr Simms notified re changes in condition since ____ (time of first phone call). Dr
states he will come in to assess client.

Entry # 3
Dr Simms assessed client and orders received. Antibiotics pending from pharmacy. Client
commenced on oxygen via nasal prongs @ 3L/minute. SpO2 96% on oxygen. Pulse 85/
min; Blood pressure 135/65. Respiratory rate 24/min. Respirations less labored, with mini-
mal accessory muscle use noted since oxygen therapy commenced. Client states he feels
‘more comfortable’ but ‘still a bit short of breath’.

What factors do you think influenced Melanie’s ability to document appropriately in this situation?
What do you think could be done that would assist Melanie to document effectively in future?

Factors that may have influenced Melanie’s ability to document appropriately include the following:
• Perhaps this is Melanie’s usual pattern of documentation? It would be helpful to know if the
lack of detail in her documentation is typical of her documentation or if it is just occurring today
— and is influenced by her workload.
• Her workload: she has several clients she is ‘concerned about’ and it is evident she is experienc-
ing a ‘busier than average’ day.
• The overall acuity of current clients in the extended care unit is ‘higher than normal’. This has
increased workload for all staff, and means there is less opportunity for her to get assistance
with her client care.
• Melanie appears to be recording all information in the nurses notes – suggesting that the unit
documentation ‘standard’ appears to narrative –style documentation. While this has advan-
tages of having all information in one area and also allows for descriptive detail, this type of
documentation takes time. This may be why Melanie’s documented entries were brief.

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 1 Applying My Learning con’t

Perspectives
CASE STUDY SCENARIO 1: MELANIE
Strategies and actions that would assist Melanie to document effectively in the future include:

• Focusing her documentation on relevant information will assist her in finding the balance be-
tween concise documentation and including sufficient detail in her documentation. For example:
» Considering all phases of a client situation in documenting
» Considering if what she documents includes enough detail so that someone who had not
been present could still fully understand the situation.
• Focusing her documentation on factual and objective information: this will assist her in provid-
ing clear, unambiguous, and complete information about client situations.
• Melanie did a reasonable job of documenting in a timely manner for three of the events with Mr.
Bell. Building from that partially established pattern will assist her in timely documentation of
all of her actions, all client data and conversations with other health care professionals.
• Workload management. This is a challenge for most nurses today. While there is no simple
answer to finding time in a busy day for documentation, it is helpful to view documentation
as one final step in any aspect of provision of care for a client — and to not consider the care
completed until documentation is done. Considering the type of documentation that supports
nurses to complete timely and appropriate documentation may be helpful. Would Melanie find
it easier to be ‘up-to-date’ with her documentation if there was a standardized documentation
tool she could use?

What are the implications of Melanie’s ineffective documentation for Mr. Bell’s outcomes?

Earlier we noted that the brief documentation entries that Melanie made were incomplete. They lacked full
information about Mr. Bell’s condition, did not provide details of her actions and did not include the nature of
the phone conversations she had had with Dr Simms. In addition, the information she did provide related to
Mr. Bell’s condition did not provide a clear, factual ‘picture’ of his status at those times. From this, it is clear
that this documentation would not allow other nurses or other health care professionals to:
• understand what Mr. Bell had experienced during that time period
• use this information in their own planning related to Mr. Bell’s care

In other words, Melanie’s inadequate documentation both makes it challenging for other health care profes-
sionals to provide optimal care for Mr. Bell (because they are not fully informed) and, potentially, also places
Mr. Bell at risk for inappropriate care. Melanie’s inadequate documentation can have adverse effects on Mr.
Bell’s outcomes.

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 1 Applying My Learning con’t

Perspectives
CASE STUDY SCENARIO 1: MELANIE
Consider the conceptual framework and directives for documentation in nursing practice. What are
the possible the implications of Melanie’s ineffective documentation for herself?

Like all Registered Nurses, Melanie is required to meet legal, professional and agency directives for docu-
mentation. Given that nurses’ documentation is a legal evidence of care provided and client’s responses to
that care, ‘what’ Melanie documented is a concern. The information missing from her documentation may
be interpreted as evidence that she had not provided safe, appropriate and ethical care for Mr. Bell in this
situation. In addition, the vague nature of her statements related to Mr. Bell’s condition, could be construed
to mean that she was not capable of appropriate assessment. In short, Melanie’s documentation places her
at risk of being accused of not providing adequate care for Mr. Bell if, for some reason, his situation became
the focus of legal proceedings.

According the BCCNM Practice Standard for Documentation, nurses’ documentation is a record of profes-
sional practice and care provided for a client and, as such, provides evidence of whether or not a nurse has
applied the nursing knowledge, skills and judgment according to their BCCNM Professional Standards of
Practice. The Practice Standard further states that nurses should document “timely and appropriate reports
of assessments, decisions about client status, plans, interventions and client outcomes” (BCCNM, 2008, p.1).
When we consider Melanie’s documentation in light of these directives, it is evident that her documenta-
tion does not align with these requirements. However, when we read the story of Melanie and Mr. Bell, we
can see that she was conscientious and committed in the care she provided for him — she assessed him
frequently, recognized the significance of his change in condition, and communicated with his physician
regularly to ensure he received appropriate care. And yet, because of the brevity of her documentation, the
vague client descriptions and missing information, her documentation does not provide evidence of her
providing care according to the Professional Standards of Practice. As we noted above, Melanie’s documen-
tation does not provide evidence of her having provided adequate care; it also places her at risk of a profes-
sional practice inquiry.

Finally, Melanie is required to follow the Extended Care Unit’s documentation policy and the agency’s
directives in her documentation. We do not have information related to these policies in this case, but can
assume that the policies will reflect legal and professional requirements for nurses’ documentation. From
this standpoint, it seems possible or even likely, that Melanie’s documentation does not meet unit or agency
requirements in this situation.

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 2 Applying My Learning

Perspectives
CASE STUDY SCENARIO 2: RICK

Consider the characteristics of effective documentation. Identify three documentation errors in this
scenario. How should Rick have documented Mr. Stivic’s care in these situations. Provide examples.

Incomplete documentation (what):

As in scenario #1, concise documentation is desirable, but Rick has omitted important information in his
documentation. Rick does not chart the chest pain assessment he performed as clear concise statements
that describe his assessment, rather he simply charts “patient experiencing chest pain”. Nurses’ charting
often lacks detail that describes accurately the care that was provided. Nurses also often miss documenting
the client’s assessment, but document the interventions that were performed (for example, Rick docu-
mented “Morphine 2 mg IV administered”).

It’s also a common error in documentation to miss documenting the evaluation of interventions. This is also
an error in Rick’s documentation. Although Mr. Stivic’s chest pain has decreased considerably with interven-
tion, it would be impossible to know this from reading Rick’s documentation.

A good test to evaluate whether your charting is satisfactory is to answer the following Question. If anoth-
er RN had to take over this patient’s assignment, do the nurses’ notes provide enough information for that
nurse to maintain consistency of safe, competent and ethical care? Would that RN

know that Mr. Stivic was short of breath and diaphoretic and whether Mr. Stivic’s chest pain had been re-
lieved, and what intervention worked for him?

Rick did perform a full pain assessment. I’d suggest he chart it like this:

Time Nurse’s notes Signature

1920 Patient arrived in ED wearing oxygen 40% by face mask. RR, R.N.
Patient is having difficulty speaking and states he is short of
breath. Patient’s skin is clammy. Patient states he is currently
experiencing chest pain 7/10. Patient states the pain started
after dinner and is ‘a bit better’ since the

paramedics gave him nitrospray. He states it was 10/10 before

the paramedics arrived. Patient describes the pain as ‘crush-
ing’ in the ‘middle of his chest’ that radiates down his left arm
and into his jaw.

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Perspectives

CASE STUDY SCENARIO 2: RICK

Further, Rick should have documented the effect, or lack of effect, of both the morphine and nitro-
glycerin on Mr. Stivic’s chest pain at initiation and with the increase in dose.

Not identifying a ‘Late Entry’ (how):

Rick didn’t complete his documentation until all nursing actions were carried out, approximately 15 minutes
after he began to provide care for Mr. Stivic. When it is not possible to document at the time of providing
care a ‘late entry’ is required. The length of time between care and documentation that is considered ‘late’
should be defined by agency policy.

Rick should have clearly identified his documentation as ‘late entries’ indicating the time the care was pro-
vided and the time of documentation.

Inappropriate documentation of assisted care (who):

Generally RNs should document the care that they personally and directly provide. Documenting for others
who are providing direct care may lead to inaccurate documentation and this could affect the continuity
and quality of client care. In situations when two nurses or a nurse and another health care provider pro-
vide care or services together (witnessed care), the RN who is assigned to the client should document the
actions and the client’s responses, noting that another RN or care provider assisted.

Rick documents Janet’s care (administration of Morphine and obtaining the 12 lead) but does not identify
Janet as the care provider. This could lead to the erroneous assumption that Rick was not assisted and
actually performed this care.

What factors do you think influenced Rick’s ability to document appropriately in this case? What do you
think could be done to support Rick to document effectively in future.

Influencing factors:
The urgency and acuity of the patient’s status
Mr. Stivic came into the ED experiencing chest pain, and was potentially experiencing a myocardial infarc-
tion. His situation demanded urgent care and interventions had to be carried out quickly to prevent and
further damage to his heart muscle. This context of urgency likely influenced Rick’s ability to document.

The staffing ratio on the unit

Rick did have Janet’s help when Mr. Stivic was admitted and this was a positive influencing factor on his
documentation. It does seem, however, that a bit more assistance may have given Rick the time to docu-
ment more completely and in a timelier manner.

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Perspectives

CASE STUDY SCENARIO 2: RICK

Rick’s knowledge of documentation

Is this Ricks typical pattern of documentation? It would be helpful to know if the lack of detail in his docu-
mentation a pattern in his documentation.

The agency policies on documentation It’s hard to know in this brief case what ‘style’ of documentation
Elsewhere General has adopted. Certainly many ED records are streamlined and contain checklists for more
standard assessment criteria while still meeting the requirements for effective documentation. It appears,
however, that Rick’s documentation is in a more narrative format. In essence, the style of documentation
used at Elsewhere General may influence Rick’s ability to document effectively.

Supporting Rick’s documentation:

Clear agency forms /policies

Elsewhere General may consider reviewing it’s documentation policies and practices and adopting or creat-
ing clear ED records based on directives that support effective documentation.

Documentation ‘refreshers’
It’s quite possible that Rick is not fully aware of his legal and professional responsibilities surrounding doc-
umentation. Rick could work with his educator to develop a plan to improve his documentation, than access
resources to help him review and/or learn more about effective documentation.

ED staffing
This is a challenge for most health care agencies today. While there is no simple answer it’s likely that more staff in
urgent and emergent situation would permit documentation to occur alongside safe, appropriate and ethical care.

What might be the implications of Rick’s ineffective documentation on Mr. Stivic’s outcomes?
A major problem was that Rick’s documentation was incomplete. It lacked full information about Mr Stivic’s
chest pain and did not provide details of the evaluation of nursing interventions to relieve his pain.

Rick’s documentation did not provide a clear, factual ‘picture’ of his status or whether it changed with intervention.
From this, it is clear that this documentation would not allow other nurses or other health care professionals to:
• understand what Mr Stivic had really experienced during that time period
• use this information in their own planning related to Mr. Stivic’s care.

Simply, Rick’s incomplete documentation makes it both challenging for other health care professionals to
provide care for Mr Stivic (because they are not fully informed) and, potentially, also places Mr Stivic at risk
for inappropriate care.

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 2 Applying My Learning con’t

Perspectives

CASE STUDY SCENARIO 2: RICK

Rick’s documentation did not appropriately describe Mr. Stivic’s care in terms of who assisted Rick
nor did it document accurately the timing of Rick and Janet’s care. These errors would not likely
affect Mr. Stivic’s outcome in this particular case however if Rick repeated these errors in other
situations, this lack of factual documentation may cause challenges for other health care providers
trying to maintain consistency of care in Rick’s absence.

Consider the conceptual framework and directives for documentation in nursing practice. What could be the
implications of ineffective documentation for Rick?

Legal and professional requirements:

Like all Registered Nurses, Rick is required to meet legal, professional and agency directives for documen-
tation. Given that nurses’ documentation is legal evidence of care provided and client’s responses to that
care, ‘what’ Rick documented is a concern. The information missing from his pain assessment documenta-
tion may be interpreted as evidence that he had not provided safe, appropriate and ethical care for Mr Stivic.
Further, the vague nature of his statements could be interpreted to mean that he lacked knowledge of ap-
propriate pain assessment or that he did not know to evaluate the effect of the interventions he provided. In
short, Rick’s documentation places him at risk of being accused of not providing adequate care for Mr Stivic
if this situation became the focus of legal proceedings.

According the BCCNM Practice Standard for Documentation, nurses’ documentation is a record of profes-
sional practice and care provided for a client and, as such, provides evidence of whether or not a nurse has
applied the nursing knowledge, skills and judgment according to their BCCNM Professional Standards of
Practice. The Practice Standard further states that nurses should document “timely and appropriate reports
of assessments, decisions about client status, plans, interventions and client outcomes” (BCCNM, 2008, p. 1).
When we consider Rick’s documentation in light of these directives, it is evident that his documentation
does not align with these requirements. His documentation is brief, provides only a vague description of
pain assessment and is missing evaluation of interventions. Rick’s documentation does not provide ev-
idence of providing care according to the Professional Standards of Practice. This places him at risk of a
professional practice inquiry.

Agency’s directives:

Finally, Rick is required to follow the Emergency Department ’s documentation policy and the agency’s
directives in his documentation. We do not have information related to these policies in this case, but can
assume that the policies will reflect legal and professional requirements for nurses’ documentation. From
this standpoint, it seems possible or even likely, that Rick’s documentation does not meet unit or agency
requirements in this situation.

Documentation in nursing practice workbook | 36