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Nov 8, 2017 in Analysis

Managing Health Care - Legal Concepts of Documentation

This section would cover the two following directions: core aspects of the documentation system in the healthcare establishments (1) and systems and methods of documentation (2).

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Core Aspects of the Documentation System in the Healthcare Establishments

While referring to the health care records management, it is important to rely on the accountability of the clinical documentation and to outline the following information. There are specially developed Codes of Ethics for the nurses. According to these codes, the nurses are responsible for applying their skills and knowledge into the practice in order to provide their patients with competent, safe and ethical care. That is why the professional activity of the nurse (in the light of the documentation process) should reflect such competent and safe nursing care. The responsibility for the documentation process is also lies on the nurses.

The personal and professional support health care records are provided in the documentation in order to support the fact of the everyday care providing to the patients by the nurses with the evidence. In addition, it is important to put an emphasis on the fact that there is a possibility of using the nursing documentation for the legal proceedings. In the case if the nursing documentation is accurate, thorough and complete, it is possible to support the fact of meeting the set of the core requirements by the particular nurse with the evidence.

It is possible to make a conclusion that the client record documentation is the indicator of the provided care. In addition, the nurses’ care is made visible by the documentation (Bastable, 2003).

The next issue to be discussed in the scopes of this paper is the legal outcomes of nursing documentation. It is important to emphasize the fact that the client health care record is considered as the legal document. The information, supporting the fact that the care is provided by the health care establishment, is included into the document. Consequently, there is a possibility of using this documentation in the cases when there is the need to answer questions, concerning the care provision accountability resolving. The chronological record of the set of events is provided by the documentation – from the patient’s admission to discharge. It is possible to use this information for the nurses’ memory refreshing in the cases when there is the need in providing the evident facts and information in the court. In the majority of cases, courts use the medical documents for the event reconstruction, dates and time establishing and in order to resolve conflict in testimony (Grant, 1997).

When the lawyer represents the nurse or doctor, one relies on the available documentation in order to establish the fact that the care has been provided in accordance with the standards and with prudence. In the same manner, the lawyer, representing the client may apply the documentation for proving the fact that there has been a set of failures in the care providing process and tactics, and consequently, in the entire process of treatment. The specific information is included into the documentation: who, what, how and why. The actual care, which has been provided, is discussed and the response of the client to the treatment and its effectiveness is given. Also, such documentation provides the assistance in confirmation of the competence and safety of provided medical treatment and care (Keatings et al, 2000).

Also, the risk management should be taken into account in the scopes of this section. It is possible to consider the client information, included into the health care record as a tool, applied in the processes of quality improvement for analysis and evaluation of the provided services and the achieved outcomes of the particular treatment procedures. In the majority of health care establishments, the standards for client documentation are set. Also, they are determined at the national level in the specific acts. These standards should be met by the facilities in the process of their accreditation. The sound basis for the quality of care appropriate measurement is created by the accurate and comprehensive documentation. In such a manner the progress toward preferred outcomes is evaluated.

While referring to the risk management program, it is important to consider the fact that it is presented as an identification system directed to the risks of clients, staff, visitors and organizational assets reduction. In order to make the risk management practice effective, there is the need of clear documentation. That is mainly caused by the fact that the audits require the health care records in order to carry out the analysis of the ongoing risk management. Potter et al (2009) consider that “The nurses’ notes are risk-management and quality assurance tools for the employer and the individual nurse”. That is why it is possible to conclude that the effective tool of the risk management is the high quality documentation, which, in turn, may be applied for and by the staff, which provides the care, the client receiving care, and the entire health care establishment (Potter et al, 2006).

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The last issue to be taken into account is the evidence-based practice facilitating. The evidence-based practice is both supported and informed by the practical and theoretical experience of the health care service providers. As it has been stated above, the core essence of the health care record is that it is an information source used by the nurses and by the scientific researchers in the particular area. That is why it is ought to be accurate one. The rich information source is provided by the documentation for the medical personnel. This information related to the client outcome evaluation and to the nursing interventions (Meiner, 1999).

Systems and Methods of Documentation

While referring to the fact that the total computerization has taken its place in the time frame of last 10-15 years, the health care records are also executed while using the PC. The principles of documentation are common for both the paper documentation and the electronic version.

Kirkley & Rewick define the online documentation as “technology that automates the capture of clinical care data. In the nursing realm, this can include assessment data, clinical findings, and nursing plans of care, nursing interventions (along with results), patient’s progress toward goals, risk assessments, discharge planning, patient education and more” (Kirkley & Rewick, 2003).

The set of the secure features is required by the electronic documentation systems in order to protect the confidentiality of the client and to prevent other existing forms of the documentation entries modifying. After completing the documentation, the entries are to be locked by the program – they should be transferred to the form of “read only” information. There is a general requirement to the practice setting policies – the access to the information should be provided to the staff of the health care establishment only in the scopes of the specific area of practice. Only selected staff is to be provided with the access to the complete information, concerning the particular client (patient). In order to guarantee the passwords and ensure security, they are to be changed at the specific time intervals. The level of access to the information is defined in accordance with the user name.

It is important to emphasize that the doctors and nurses should be allowed to access to the E-health system only by using their personal user name and password. That is done in order to ensure that the particular nurse or doctor has accessed the system at the specific time and place.

In the case if there are two forms of documentation in the health care establishment (paper and electronic), there is the need of the continuity of care maintenance. There is a general requirement in such a case to identify using the paper-basedhealth-care records of the E-health system. If the paper health care record is used when there are some technical problems with the electronic system, the reader should be redirected to the paper health care record.

There is a requirement to the care provider to put a signature in the E-health record. It is important to emphasize the fact that the electronic signatures are valid. The core purpose of using them is demonstration of the accountability. These signatures are technically accessible only to the person, who is identified by thatsignature.

If the incorrect entries take their place, they must be corrected. The remark on the corrector, the time of correction and place are obligatory.

The awareness of the health care establishment personnel in the ways of E-documentation correction is also obligatory. It is important to emphasize the fact that similarly to other forms of documentation, the information, which has been used for the health care record, cannot be deleted.

The nurse or doctor is required to refer to their employer’s policy in the cases when the additions or changes are made to the E-health record (Kirkley & Rewick, 2003).

All the entries to the health care record are to be voluntary. In the case if the entry is late, it should be marked correspondingly. All the corrections, alterations or deletions to the E-health record are to be documented carefully. Also the date is to be put, including the hour and the signature of the nurse or doctor, who is making the additions or changes to the file.

There is a set of the effective documentation techniques, which are directed for the appropriate solutions for the particular health care organization. The narrative documentation technique is considered as the traditional method for the provided nursing care recording. The documentation is accomplished in the form of story. There is not any organized framework – the data is recorded in the form of the progress notes. The reader is often required to sort the information.

The Problem-Orientated Medical Record (POMR) implies the single list of client problems, which is made by the members of the health care team. The basis for the POMR method is formed by the nursing process. There are the following advantages of such approach:

  • The core emphasis is put on the client’s perceptions of their problems;
  • The continuous evaluation of the care plan and its revision are required;
  • Greater continuity of care is provided among the members of the health care team;
  • The effective communication is enhanced among the members of the health care team;
  • The efficiency in the information collection is increased;
  • The chronological order for the information is provided, and makes it easy-to-read;
  • The use of the nursing process is reinforced.

In the case of the POMR, the chronological problem number is not repeated in the time frames of one hospitalization. After treatment has been completed and the problem has been resolved—the modification of the list is made by checking off the area next to the listing or by signing a space. Also, the date of the problem resolution is noted next to the signature.

While referring to the SOAP/IER method, it is important to rely on the following information – it is the problem-orientated documentation method. It is structured in such a manner when the notes of the narrative progress are written by the members of the health care team. The SOAPIE, SOAP or SOAPIER format is applied in this case. Meiner (1999) gives the following interpretation of the abbreviation:

  • Objective - the care provider’s observations and tests;
  • Subjective - the client’s observations;
  • Assessment - the care provider’s understanding;
  • Plans - advice, action, goals;
  • Evaluation - how outcomes of care are evaluated;
  • Intervention - when an intervention was identified and changed to meet client’s needs;
  • Revision - when changes to the original problem come from revised interventions, outcomes of care or time lines that is used to denote changes (Meiner, 1999).

The PIE (Problem; Intervention; Evaluation) method implied that there are numbers and labels (given in accordance with the client’s problems) for all the notes. The resolved problems are eliminated from the daily documentation after the review is done by the doctor or nurse. The daily documentation is done only for the continuing problems (Potter et al., 2006).

Focus Charting (DAR) is documentation technique that includes subjective and objective data, actions and the clients’ response. The core emphasis of this documentation technique is made on avoiding the formal documenting of problems only.

To conclude the chapter, it is important to put an emphasis on the fact that regardless the chosen method, nurses and doctors are responsible for the treatment, data keeping and for the outcomes.


Written communication skills are very important for the precise documentation of each of the above listed nursing practice components. In the case if the document is competed perfectly, it may be further applied as the valuable tool for the effective communication between the health care providers within the clinic support.

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