INTERDISCIPLINARY CLINICAL MANUAL
Policy & Procedure
TITLE:
Clinical Documentation in the
Health Record
January 30, 2014
Date
Issued:
Applies To:
NUMBER:
CC 04-040
Page
1 of 13
Holders of the Capital Health Interdisciplinary Clinical Manual
POLICY
1. Documentation in the health record serves as a comprehensive communication tool for
health professionals facilitating the provision, co-ordination and continuity of safe care
for patients. As such, documentation is required to meet legislative, professional/college,
Accreditation Canada and the Nova Scotia Department of Health and Wellness (DHW)
reporting requirements.
1.1. All healthcare professionals in Capital Health are to record notes in the patient
health record in accordance with approved guidelines as outlined in this policy.
2. All paper health records are to include a Healthcare Provider Signature Identification
Sheet (CD2407MR) to be completed by any health care provider who provides care to a
patient and is required to document that care in the health record.
2.1. The Healthcare Provider Signature Identification Sheet (CD2407MR) is to be placed
at the front of the Health Record.
Note: Electronic health records have processes to identify the health care provider.
2.2. For Ambulatory Care Areas, Offender Health Services, and Pharmacy Departments,
refer to Appendix C for options to implement the Healthcare Provider Signature
Identification sheet.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the electronic file version prior to use.
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CC 04-040
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3. Abbreviations:
3.1. Use of abbreviations is to be kept to a minimum
3.2. When used for medication orders, abbreviations are to comply with restrictions as
noted in:
3.2.1. Institute for Safe Medication Practices (ISMP) Canada’s DO NOT Use Dangerous Abbreviations, Symbols and Dose Designations http://www.ismpcanada.org/download/ISMPCanadaListOfDangerousAbbreviations.pdf
4. The Healthcare Provider (HCP), who provides direct patient care:
4.1. documents with the understanding that the patient/family has the right to access the
patient’s health record
4.2. maintains the confidentiality of the information documented in the health record;
does not share information outside of the other healthcare providers without
informed patient consent or other proper authority. (Refer to Release of Information
from the Health Record CH 30-015.)
5. All information generated by Capital Health HCPs is to be on Capital Health Horizon
Patient Folder (HPF) formatted forms that have been approved for use in the health
record and meet HPF standards. Encounter labels, patient demographic information,
and document type bar codes are to be visible on forms prior to the addition of written
information.
6. The development of policies to explain how to complete a specific form is not required.
(A well-developed form should be self-explanatory; if guidelines are required, these
should be added to the back of a form).
6.1. All internal health record forms are to comply with The Health Record Standards for
the Creation/Revision of Clinical Health Record Forms. (Refer to Related
Documents)
7. The method for documenting in progress notes is to adhere to current site, program or
discipline specific guidelines (e.g. focus charting, charting by exception, etc.)
8. Altering the Health Record is not acceptable. Any of the following may be considered
altering:
8.1. Adding to an existing record at a later time or date without indicating the addition is a
late entry. (refer to Appendix A –late entries)
8.2. Intentionally placing inaccurate information into the record
8.3. Intentionally omitting significant facts
8.4. Dating a record to make it appear as if written at an earlier time
8.5. Rewriting or altering the record
8.6. Destroying records without authority
8.7. Adding to or editing another’s notes.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the electronic file version prior to use.
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CC 04-040
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9. New Forms
9.1. The number of variations of the same form (e.g. MAR, Consent, Flow Sheet, etc.) is
to be streamlined as much as possible.
9.1.1. Prior to creating a new form, similar forms already available must be reviewed
and assessed as to possibility of adopting an existing form.
GUIDING PRINCIPLES
1. Clinical documentation in the health record includes any and all information that relates
to the care of the patient during an encounter. It is designed to evaluate the current
status of the patient, assist in developing a plan of care, evaluate the care given, and
provide for continuity of care (A Guide to Better Physician Documentation, 2006).
Specifically, it:
1.1. Provides a permanent, accurate, timely and chronological record of health
information;
1.2. Provides information to assist in the development and evaluation of the patient plan
of care;
1.3. Provides information for measurement, evaluation and improvement opportunities;
1.4. Demonstrates individual HCP’s accountability for the care provided;
1.5. Facilitates research, future decision-making and best practice;
1.6. Provides a written record of the care received by the patient should the patient or
substitute decision maker request to review;
1.7. Provides a factual sequence of events for insurance providers, police, legal
services, and other agencies that meet access requirements.
2. Clinical documentation should be brief, concise, accurate, and pertinent to the delivery
of care.
DEFINITIONS
Horizon Patient Folder
(HPF):
HPF is an electronic document storage system used to
store patient information after the visit or care encounter.
It is a record storage and archive system that has viewing
capability of scanned documents.
Health Care Provider:
Care providers who plan and direct the delivery of care as
well as those who deliver hands on care (e.g.: physicians,
registered nurses, licensed practical nurses,
physiotherapists, physiotherapy assistants, etc.)
COLD Feed:
(Computer Output to Laser Disc) Documentation
generated during an encounter with the patient which is
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the electronic file version prior to use.
Clinical Documentation in the Health Record
CC 04-040
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electronically sent upon patient discharge to the health
record for storage.
Encounter:
Any patient visit to Capital Health facilities within the
hospital or community setting
Encounter Number:
A unique identifier assigned to a patient where registration
is a prerequisite to ensuring that documentation of the
encounter is completed. An encounter may be face to
face, teleconference, telephone, email, or via
discussions/consults among providers along the
continuum of care where the outcome is to be documented
on the health record.
Late Entry
An entry out of chronological order, which refers back to
information relevant to a previous shift
PROCEDURE
1. Ensure that documentation is complete for every health care encounter, on registration,
admission, transfer, discharge, and throughout the episode of care.
2. Document all significant findings and interventions.
2.1. Use the progress notes for documentation of significant/abnormal findings,
assessments, interventions and outcomes of care.
2.2. Use flow-sheets for documentation of expected/usual care activities.
3. Document only on approved Capital Health HPF patient health record forms, following
specific guidelines for the use of each form.
3.1. Refer to The Health Record Standards for the Creation/Revision of Clinical
Health Record Forms (Refer to Policy Statement # 9).
3.2. Clearly indicate the patient’s full name, encounter number, health card
number and date of birth on all forms.
3.3. Affix the required labels to the form prior to the addition of written notes so
that the written notes are not compromised, and the label is not affixed over
other information.
3.4. Ensure that all documents (forms) sent to Health Information Services (HIS)
for inclusion in the health record have the encounter bar code label and the
demographic information.
4. As per policy statement #3, limit use of abbreviations whenever possible. If use of an
abbreviation is deemed necessary:
4.1. Use only acceptable abbreviations and acronyms as found in a standard
medical dictionary.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the electronic file version prior to use.
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CC 04-040
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Note: Stedman’s is the dictionary of choice – available on line for Capital
Health Staff
From a Capital Health computer:
http://www.statref.com/resources/PDFs/SROnline/StedmanQuickGuide.pdf
From a computer not on the Capital Health network:
https://libraryproxy.cdha.nshealth.ca/login?url=http://www.statref.com/resourc
es/PDFs/SROnline/StedmanQuickGuide.pdf
Other standard medical dictionaries (e.g. Mosby’s) are also acceptable.
4.2. For medication orders, refer to Appendix B for the list of abbreviations
recommended and approved by the District Drugs and Therapeutics
committee.
4.3. Initially write out the full word or phrase, putting the abbreviation in brackets
4.4. Check the ISMP Canada ‘Do Not Use List’ (Refer to policy statement 3) and
avoid use of dangerous abbreviations.
4.5. Avoid abbreviations that have more than one meaning in the context of use.
Example; A commonly used abbreviation is ‘OD’. The intended meaning is ‘once
daily’, but is often mistaken for ‘right eye’. The recommended action is to write out
as appropriate (‘once daily’ or ‘right eye’).
5. When documenting on paper health records, complete the Healthcare Provider
Signature Identification Sheet (CD2407MR) when first providing care to the patient.
When signing off an entry, include written signature and designation as outlined on the
documentation form being used.
Note: Refer to Appendix C for options to implement the Healthcare Provider Signature
Identification Sheet in Ambulatory Care areas, Offender Health Services, and Pharmacy
Departments
5.1. For medication safety, authorized prescribers include printed name and
license number when signing all medication orders.
5.2. Pharmacists include printed name when writing a Therapeutic Interchange
order.
5.3. Healthcare Professional students indicate student status (E.g.: student nurses
use ‘SN’ to indicate designation.)
6. Adhere to general standards of documentation as outlined in Appendix A.
Note: Individual Health Professionals may have additional documentation
standards to which they must abide.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the electronic file version prior to use.
Clinical Documentation in the Health Record
CC 04-040
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RELATED DOCUMENTS
Policies
CH 30-015
CH 30-017
CH 30-055
CH 70-040
CH 100-055
CH 100-040
SS 30-020
Release of Information from the Health Record
Capital Health Patient Health Record
Health Records Form Management
Patient Identification and Same Name Alert
Retention of Documents
Date Formats
Horizon Surgical Manager Documentation During Downtime
Forms
Healthcare Provider Signature Identification Sheet (CD2407MR)
Appendices
Appendix A – General Standards of Documentation
Appendix B - Acceptable Abbreviations, Medication Orders
Appendix C - Health Care Provider Signature Forms – Ambulatory Care Areas, Offender
Health Services, Pharmacy
Other
The Health Record Standards for the Creation/Revision of Clinical Health Record Forms.
(Available on the Capital Health Intranet – Forms page - Health Record Forms – Forms
Development page
CDHA Medical Staff - By-laws, Rules and Regulations
REFERENCES
Capital Health District Drugs and Therapeutics Committee. Abbreviations, Medication
Order.
College of Licensed Practical Nurses of Nova Scotia. (2007). Documentation – Practice
Guideline. Retrieved from
http://www.clpnns.ca/practiceguidelines/practiceguidelinesdocs/Documentation_Dec1707.p
df
College of Registered Nurses of NS. (2005). Documentation Guidelines for Registered
Nurses. Retrieved from
http://www.crnns.ca/documents/CRNNS%20Documentation%20Guidelines%202005.pdf
Institute for Safe Medication Practices. List of Error Prone abbreviations, Symbols and Dose
Designations. Retrieved from http://www.ismp.org/Tools/errorproneabbreviations.pdf
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the electronic file version prior to use.
Clinical Documentation in the Health Record
CC 04-040
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Institute for Safe Utilization Practices (ISMP). Dangerous Abbreviations List. Retrieved from
http://www.ismp.org/msaarticles/specialissuetablePrint.htm
National Coordinating Council for Medication Error, Reporting and Prevention. Dangerous
Abbreviations. Retrieved from http://www.nccmerp.org/dangerousAbbrev.html
A Guide to Better Physician Documentation; Physician Documentation Expert Panel
November 2006 Retrieved from
http://www.health.gov.on.ca/transformation/providers/information/pdf/guide_bpd.pdf
***
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the electronic file version prior to use.
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CC 04-040
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Appendix A
1.
2.
3.
4.

Documentation Standards
Write legibly using black ink only or in approved and supported electronic
documentation tools.
Do not use felt tip, gel pens, coloured ink, or pencils as notes may not be legible when
scanned.
Exception – Red ink may be used on the MAR to underline/circle specific
documentation to draw attention to an issue. (Note: as per above, may not be visible in
HPF)
Document objectively and in a factual nature:
3.1. Avoid comments that could be interpreted as biased or judgmental. Write only
objective descriptions of an individual’s behaviour, and quote specific comments
from patients, family members or other care providers as appropriate.
3.2. Ensure that statements do not contain retaliatory, rude, discriminatory and
demeaning comments about the person, person’s family.
3.3. Make all statements honestly and in the performance of duties.
3.4. Write all entries chronologically as events occur, and as close to the actual event as
possible. (Complete all documentation by the end of the scheduled shift.)
Record information concisely, and include only essential information:
4.1. Follow the documentation format for the progress/nurses notes as per the specific
site or clinical care area.
4.2. Ensure that terminology, abbreviations and standard units of date, time and
measure are uniform throughout the program or service, both on forms and in the
uses of electronic data processing and storage systems for the patient health
record.
4.3. Record all standard units of measure in metric.
Exception– Reports generated by LIS (Laboratory Information System) which is
required, by the Canadian Standards Association, to report results in Standard
International Units.
4.3.1. When the HCP verbally reports POCT results to clinicians, the HCP also
documents the results, units of measure and methods used to obtain those
results in a written format and identified as POCT results.
4.3.2. Record all dates year/month/day utilizing full digit backfill, i.e. yyyy/mm/dd.
(Refer to Date Formats CH 100-040 policy)
4.3.3. Use the 2400 hour clock when referring to time of day or night i.e. hhmm.
4.3.4. Ensure that all entries denote:

date

recorded entry time that the documentation occurred

signature and co-signature when required
Sign all entries (minimum of first initial and full surname) and include professional
designation (e;g.: RN, PT, MD. Etc)
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the electronic file version prior to use.
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5. Late Entries:
5.1. Active Paper Health Record in Clinical Care Areas
5.1.1. Add the entry to the first available line or in the appropriate block/section.
5.1.2. Label the entry “late entry”, to indicate it is out of sequence
5.1.3. Record the current date and time of the entry.
5.1.4. If a note is written, indicate the date and time that the entry should have been
made in the body of the note.
5.2. Post Scanning into HPF
5.2.1. Print the appropriate bar-coded form and add the late entry. Ensure that the
original information remains visible with the late entry data noted as per
above. (The original form will be moved to the “Mistaken Entry” folder and the
form with the late entry will be rescanned and indexed.)
Note: If an entry is required 24 hours or more after the care was completed, or after the
patient has left, follow the above procedures and label the entry ‘Addendum to Care’
6. Mistaken Entries
6.1. The original writer corrects hand written mistaken entries promptly and in a
consistent manner:
6.1.1. Draw a single line through the entry so that it is still readable.
6.1.2. Write “Mistaken Entry” above or beside the original entry. Avoid the use of the
word ‘error’.
6.1.3. Write the date and initial beside the “mistaken entry”.
6.1.4. Do not use correction fluid, erasers or labels to cover up mistaken entries.
6.1.5. Correct mistaken entries in a computerized health record as per processes
outlined for specific electronic systems.
Example:
 For Horizon Surgical Manager (HSM) corrections to mistaken entries,
refer to SS 30-012 Correction of the Patient Care Record.
 For Radiology Information System (RIS), enter addendums into the
system; corrections are then COLD fed to other information systems.
6.1.6. Before applying an electronic signature, the Healthcare Provider reviews
entries for completeness and accuracy, correcting or modifying as needed.
Note – Healthcare Professionals have 10 days from the date the report was
transcribed to make revisions to Dictated but not Read Reports. After 10 days
the report is considered a final report. Changes are through the addendum
process.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the electronic file version prior to use.
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7. Requests for Corrections or Changes within the Legal Health Record:
Under Personal Health Information Act patients have the right to request changes to source
documentation generated within our facility. There are certain exceptions where we are not
required to grant requests, such as when the information consists of the professional
opinion or observation of clinical staff.
Requests for corrections or changes within the legal health record must be received in
writing from the patient and sent to the Manager, Health Information Services. The request
for correction or changes will be sent to the clinician responsible for the original
documentation. The clinician must review the request and making the required changes or
deny the request within 15 days of receipt and return to the Manager, Health Information
Services for response to the patient. Capital Health is legally required to respond to the
patient either granting or refusing their request within the timeframe set by law (PHIA).
7.1 Processing Approved Changes:
7.1.1 Changes to handwritten documentation must be completed by the clinician
making a mistaken entry notation on the document. Documents are available to be
printed from HPF for notation by contacting the Health Information Services
Department. Upon changing patient documentation a copy of the document(s) must
be sent to Quality Control, Health Information Services Department be filed in the
patient record. Documents required for the legal health record for correction include
the amended document and a copy of the written patient request which is signed
indicating “Approved By” and the clinician name.
7.1.2 Changes to system generated reports (cold feeds) must be completed by the
clinician completing an addendum in the originating system application. Clinicians
are also required to sign the patient request indicating “Approved By” and return the
request to Quality Control, Health Information Services for filing on the legal health
record.
7.2 Clinicians and custodians of the information have the right to refuse or deny request
for changes when it is believed on reasonable grounds that a request for correction
is:
A) frivolous or vexatious; or
B) is part of a pattern of conduct that amounts to an abuse of the right of
correction
7.2.1 Processing Denied Changes:
Clinicians are required to sign the patient request indicating “Denied” and
provide a supporting letter indicating the purpose/reason for denial and return
both documents to Quality Control, Health Information Services for filing on
the legal health record.
7.3 The Manager, Health Information Services will ensure the patient is notified of the
status upon completion of the request.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the electronic file version prior to use.
Appendix B
Approved Abbreviations for Medication Orders
The following are recommendations of the Drugs and Therapeutics Committee for the use of abbreviations
when writing medication orders.
Abbreviation
Meaning
Abbreviation
Meaning
ac
Before meals, food
mmol
Millimole
am
Morning
NKA
No known allergies
amp
ampule
NG
Nasogastric
ASAP
As soon as possible
NPO
Nothing by mouth
bid
Twice a day
pc
After meals, food
BP
Blood pressure
pm
Afternoon
cap
Capsule
po
By mouth
cm
Centimetre
post-op
Post-operative
CrCl
Creatinine Clearance
pr
Per-rectum
crm
Cream
pre-op
Pre-operatively
g
Gram
prn
When necessary
gtt
Drop
pwd
Powder
h
Hour
pv
Per vagina
HR
Heart rate
qid
Four times per day
hs
At bedtime
q____h
Every____ hour(s)
ID
Intradermal
q____min
Every_____minute(s)
IM
Intramuscular
sol
Solution
IV
Intravenous
stat
At once
kg
Kilogram
subcut
Subcutaneous
L
Litre
SL
Sublingual
liq
Liquid
supp
Suppository
mcg
Microgram
susp
Suspension
MDI
Meter dose inhaler
tab
Tablet
mEq
Milliequivalent
temp
Temperature
mg
Milligram
TPN
Total Parenteral Nutrition
tid
Three times daily
mL
Millilitre
ung
Ointment
min
Minute
ut dict
As directed
mmHg
Millimetres of mercury
WA
While awake
x
“Times” or “for”
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against the electronic file version prior to use.
Clinical Documentation in the Health Record
CC 04-040
Page 12 of 13
OTHER RECOMMENDATIONS:
Always use space between drug name, dose and unit of measure.
Do not use abbreviation D/C when ordering a discontinuation of drugs. Spell out Discontinue.
REFERENCES:
“Dangerous Abbreviations List”, Institute for Safe Utilization Practices (ISMP), See Internet
http://www.ismp.org/msaarticles/specialissuetablePrint.htm
“Dangerous Abbreviations” National Coordinating Council for Medication Error, Reporting and Prevention,
See Internet http://www.nccmerp.org/dangerousAbbrev.html
Health Record Forms Development Guidelines
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked
against the electronic file version prior to use.
Clinical Documentation in the Health Record
CC 04-040
Page 13 of 13
Appendix C
Health Care Provider Signature Forms – Ambulatory Care Areas, Offender
Health Services, Pharmacy
Due to high volumes of patients, or lack of access to the health record, Ambulatory Care areas,
Offender Health Services, and Pharmacists may not be able to sign a Healthcare Provider
Signature Identification Sheet (CD2407MR) for each patient. These areas may choose whichever
of the following options that best suits their particular practice setting.
Option #1
Retain a Healthcare Provider Signature Identification Sheet for those patients that have ‘series’
visits to the clinic. Send for scanning into HPF when the patient has been discharged or when the
signature sheet is full and a new one started.
Option #2
For patients with ‘series’ visits and who are cared for primarily by the same healthcare providers on
each visit, complete the Healthcare Provider Signature Identification Sheet at the initial visit, and
send to HPF. No further signature sheet will be required, unless a new healthcare provider cares for
the patient at a subsequent visit, in which case the HCP completes the sheet and sends to HPF for
scanning.
Note: For both options #1 and #2, the HCP needs only to complete the Healthcare Provider
Signature Identification Sheet once per patient per series visit.
Option #3
For areas with large volumes of patients and for pharmacy departments (where pharmacists write
and deliver or electronically submit via fax therapeutic interchanges, order clarifications and
telephone orders but don’t have access to the health record), have all HCPs sign a Healthcare
Provider Signature Identification form. Retain in the area on a permanent basis; have new HCPs
sign when beginning to work in the specific area.
Note 1: In this case, the Healthcare Provider Signature Identification form is not associated with a
specific patient, but is available for reference.
Note 2: Pharmacists writing therapeutic interchanges, order clarifications or verbal orders on a
patient health record while in a patient care area and having access to the health record are
required to complete the patient specific Healthcare Provider Signature Identification form.
Note 3: The Health Care Provider Signature Identification Form for pharmacists will be available on
the Pharmacy intranet page.
Option #4
In ambulatory care areas the health care provider need not sign a signature sheet provided there
is a printed name, signature and designation on an existing ambulatory care form.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked
against the electronic file version prior to use.