DOCUMENTATION STANDARDS

1. To whom it happened

2. When it happened 

3. What happened

4. Where it happened 

5. Why it happened

6. The result of what happened

7. By whom it happened

Patient/client’s name and home address;

Patient/client’s date of birth and gender;

Patient/client’s health number; and

ID number.

The patient/client’s PHR must also include information as to who is/are the Most Responsible Physician(s) (MRP) (or other health professional(s), if applicable) such as:

the name of the primary care physician and any other health care professional (e.g., Nurse Practitioner); and/or

the name of any admitting, attending and/or referring physician or health care professional.

Reason for referral and/or diagnosis

If documenting after an amount of time has passed, the entry must clearly be identified as a late entry and should note the time of the event and the time of the late entry as well as the appropriate identification. Documenting activities out of chronological order may suggest that the record is not accurate, and for that reason is not ideal. If using paper-based PHRs, never leave blank lines for someone else to insert notes. If there are blanks in your record, remember to put a single line through the area to ensure there is not opportunity for the original record to be altered. Also, inserted text or text that extends beyond the recognized writing/recording area may suggest that the notations were made as an afterthought or to conceal activities.

An essential component of effective documentation is a comprehensive summary of the patient/client’s clinical history.

This should include such information as:

date and time for each patient/client contact;

information about every patient/client visit and examination, assessment, intervention, diagnostic procedure performed by the Member;

information about every clinical finding and assessment made by the Member (e.g. ABG results);

information about all advice and instruction given by the Member to the patient/client and/or family member, advocate or caregiver by any method (e.g. in person, telephone, email);

information about every referral of the patient/client by the Member to another health professional;

a financial record if the patient/client is charged a fee;

information about a procedure or plan of care that was commenced but not completed, including the reasons for non-completion and the original of any written consent; and/or

any reason a patient/client provides for canceling an appointment, if applicable.

Generally, there are three (3) situations that commonly arise regarding consent and documentation:

1. Patient/client has provided their consent to whoever proposed the treatment plan (usually the most responsible physician) and is someone other than the RT. This is commonly referred to as Third Party Consent. The patient/client appears to understand and agree to the plan. In this situation, the RT is not required to document consent, although in some circumstances it may be appropriate to do so. Typically, the higher risk associated with an intervention, the more likely an RT would document the consent.

Third-Party Consent

The Health Care Consent Act (HCCA) also allows for a plan of treatment to be proposed by one health care practitioner on behalf of the health care team involved in the plan. This is referred to as “third-party consent” and is acceptable practice provided the consent is informed and obtained prior to initiating the treatment.

2. It is unclear whether the patient has provided consent and the RT is the one performing the procedure. In this situation, the RT is accountable for ensuring that third party consent has been obtained. If the RT has any doubt whether informed consent has been obtained, it is their professional obligation to obtain it and to document accordingly.

3. In any case where treatment is given without obtaining consent, RTs should document their opinions with respect to the patient/client’s capacity, as well as all actions taken.

Patients/clients have the right to refuse or withdraw their consent to treatment at any time – provided they are deemed to be capable of giving or withholding consent [see Responsibilities under Consent Legislation PPG]. If a patient/client chooses not to accept a proposed intervention, document the:

date and time;

a description of the proposed intervention and the reasons given for providing it;

reason(s) given by the patient/client;

information that may have been given for the proposed intervention and the possible outcomes of patient/client not receiving the proposed treatment;

individuals that were informed about the patient’s decision (e.g., prescriber); and

recommendations for alternatives, if any.

Adverse events are all unintended injuries or complications that occur during the provision of health care services. Critical incidents are adverse events so severe that they result in the actual or potential loss of life, limb or physical function.

A patient safety or adverse event report is a record subject to all of the standards of documentation. If you complete an incident report, it’s important to remember that information about the incident should also be included in the patient/client’s chart.

Most hospitals have specific protocols and procedures for documenting cardiac and respiratory arrests. It is the RT’s responsibility to accurately document their activities at these events (e.g., medication administered, defibrillation attempts, endotracheal intubation, etc.). The date, time and outcome of all interventions must be recorded.

As part of the health care team (and in collaboration with patients/clients and their families), RTs are often involved in some aspect of end-of-life care (e.g., answering family member’s questions about what to expect when life support is withdrawn). When a patient/client is going through the process of withdrawing care, clear and accurate documentation is essential. Unfortunately, research has demonstrated that this often is not the case. For example, a 2011 study published in the BMC Palliative Care Journal found a lack of a systematic approach to the recording of discussions with patients or caregivers about these kinds of issues.

Some aspects that RTs should consider when documenting their involvement in end-of-life care are as follows:

the support provided to the family in preparation for and during withdrawal of care;

any involvement in end-of-life discussion;

supportive care provided to the patient/client during withdrawal; and

any advance directives or expressed wishes of the patient/client.

Record keeping for point of care testing should be treated in a way consistent with the legislation and/or this guideline. Demographic information, date, time and identity and the credentials of the person performing the procedure must be documented and included directly on the test results. Results obtained from the point of care testing should be clearly distinguishable in the health record from those obtained from other sources. Records of quality control results and proficiency testing performance should be maintained for each device.

CRTO Members are encouraged to seek clarification from their employers regarding any requirements when using thermal paper for printing test results (for example – bedside spirometers, oximeters and other diagnostic equipment). Thermal paper degrades over time and has a relatively short shelf life. Many facilities are now stipulating that any test results printed on thermal paper should be photocopied to ensure the record is viable for the length of time it must be kept, according to legislation.

Documentation related to a patient/client transport should include the particulars of any interventions and/or monitoring performed during the transport and the details of the transfer of care at the end of the transport. The type of transport should also be documented (e.g., intrahospital, interhospital, air, land).

The principles and standards related to documentation of telephone practice are the same as those for face-to-face practice. The following elements should be documented:

Consider using a log book for this purpose and advocating with your employer to develop standards around telephone and email practice.

Objective documentation consists of unbiased observations and witnessed signs that a patient/client displays, as well as symptoms that have been directly stated by the patient/client. Information documented in the PHR should be a factual representation of what actually occurred (objective), as opposed to the RT’s interpretations of the events (subjective). Documenting subjective comments can be harmful to both the patient/client’s well-being (can impede effective communication) and to the RT’s professional reputation. Below are some examples of objective and subjective statements.

the result of the intervention;

Anyone reading the documentation must be able to clearly identify the individual performing the activity or making the recording, while making sure there is a unique identifier for that person (e.g., signature). This means that a CRTO Member should provide a signature at the end of the entry with at least a first initial, last name and professional designation (abbreviation is acceptable).

A signature (and/or initials) certifies the information provided and gives assurance that the record of activity, assessment, behavior or procedure is accurate and complete. CRTO Members must not give permission to anyone else to sign their name to a document under any circumstances. Members also must not sign someone else’s name to a document.

When an RRT is supervising another individual [usually a Student Respiratory Therapist (SRT); however, it may also be an RRT who has Terms, Conditions and Limitations (TCLs) on their certificate of registration], it is essential that the documentation accurately reflect the following:

1. What degree of supervision was provided; and

2. Who performed each task and who provided supervision.

Direct Supervision occurs when the SRT (or Member with TCLs) performs a controlled act with the RRT observing and overseeing the task. In these cases, the student (or Member with TCLs) must document in the patient/client’s PHR that they have performed the procedure(s) under “direct supervision”. The supervising RRT must then co-sign the entry in the patient/client PHR stating that the documented activity took place “under direct supervision”. An example of direct supervision would be a supervising RRT, physically observing and guiding the performance of arterial blood gas sample being drawn by an SRT.

General Supervision involves those situations where a determination has been made that the SRT (or Member with TCLs) can perform a given controlled act independently. Where activities or procedures are being done under general supervision, the supervising RRT must not co-sign the student’s documentation. The reason for this is that co-signing means the RRT is attesting to the accuracy of the documentation. If they did not witness the task(s) performed, they have no absolute way of knowing if the documentation is correct. Only the person who performed the activity/procedure or has the patient contact should document and sign the entry.

RTs very often work as part of a multidisciplinary team that collectively provides diverse and overlapping health care services. As with any well-functioning group, effective communication within and outside of the team is vital. In order to facilitate this communication, many health care facilities have moved towards more integrated, interdisciplinary documentation records.

If an RT does not believe that a particular order or a proposed plan of treatment is in the patient/client’s best interest, it is their professional responsibility not to proceed with the intervention. In addition, the RT is expected to:

the rationale for their refusal to provide treatment;

when notice was provided to the prescriber and details about discussion with prescriber, if applicable; and

suggested alternatives, if applicable.

Withdrawing or withholding care/services from a patient is not common and only used as a last resort in a strategic plan for managing abuse/violence. However, it may become necessary if there is a significant threat or risk of serious injury to a member of the staff, fellow patient or a visitor. Balancing the patient’s interest in receiving care against the risk of harm to others is particularly difficult in situations where the care is necessary or time-sensitive. Where it becomes necessary to withdraw or withhold care/services, documentation should include the following:

the circumstances leading up to and including the withdrawal of care/service including the information given to the patient of the action that will be taken if the behavior continues;

the process used by you (e.g., employer established guidelines for managing violent or abusive behavior by patients) including all attempted efforts to resolve the situation;