Complete, accurate, objective and timely documentation is essential to the continuity of care and is the primary mode of communication among health professionals.
There are seven (7) basic standards related to documentation based on the expectation that anyone reading the patient/client’s PHR should be able to clearly determine:
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
With respect to PHRs, this means that no matter what type or kind of charting is used at a particular facility, anyone reviewing the chart must be able to determine that the above standards have been met. An employer’s policies and procedures related to documentation should support the seven standards, as outlined above.
Applying The Documentation Standard
I. To Whom It Happened
The standard is that anyone reading the documentation must clearly be able to identify the patient/client who was the recipient of the health care services. Therefore, the PHR must contain Unique Patient/Client Identifiers, such as:
Patient/client’s name and home address;
Patient/client’s date of birth and gender;
Patient/client’s health number; and
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
PHRs may become separated; therefore, it’s important to ensure that required identifiers (e.g., name, date of birth, OHIP number) are on every page of the PHR and on each piece of the document that pertains to that patient (e.g., ventilator flow sheet, overnight oximetry results).
II. When it Happened
Documentation should be timely and chronological. Common sense suggests the more time that passes between the activity and recording it, the higher the possibility of errors. Documentation that is timely and chronological lends credibility to the accuracy of the record. The date and time must be included in all entries and must be unambiguous. The use of the 24-hour clock is encouraged.
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.
Health records must be completed as soon after the event as possible and you are obligated to complete the record before you “finish your shift”. Also, do not document before giving patient/client care.
A Late Entry is an entry into a record that is made more than thirty (30) minutes after the intervention occurred or when the entry is documenting events chronologically out of sequence.
III. What Happened
Clinically Relevant History
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.
Documenting About Consent
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.
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.
For Example… A patient/client consents to a treatment plan that includes intubation and ventilation, if required. However, a family member feels that this course of action is futile and potentially harmful. The patient/client then goes into respiratory failure and the RT intubates them. In this scenario, it is likely important for the RT to document the conversation they had with the patient regarding their previous consent to the procedure.
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.
For Example… A patient/client shows up with a requisition for a cardiac stress test in a business suit and seems to have no idea what the test entails. In this scenario, the RT can assume that third-party consent has not been obtained and should provide the necessary information in order to obtain informed consent.
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.
For Example…A patient/client arrives in Emergency obtunded and requiring intubation. They are unable to consent to the procedure; however, delaying this procedure will conceivably result in harm to the patient/client. In this scenario, it is permissible under the HCCA to provide the necessary treatment, but the RT should still document their opinions with respect to capacity and all actions taken to obtain consent from a substitute decision maker, if available.
When employer policy requires written consent for a given intervention (e.g., Pulmonary Function Test), the RT must ensure that there is a signed consent prior to the intervention being initiated.
For more information please see the CRTO Responsibilities Under Consent Legislation PPG.
Documenting Patient/client’s Decision To Not Accept A Plan Of Treatment/Intervention
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.
Reporting Adverse Events And Critical Incidents
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.
When signing a cardiac arrest record, it is important to understand that you are attesting to the accuracy of that record. If the arrest record needs to be modified to reflect your role at the arrest, you should ensure that the record is amended in an appropriate manner.
End of Life Documentation
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.
An RT is providing care to an individual who is in the final stage of their life and is required to take the patient/client off the ventilator and remove their ETT. In this situation, the RT’s documentation should include not only these actions, but also the conversation they had with the family prior to, during and after the patient/client was taken off life support.
IV. Where it Happened
The record should reference where the patient /client received the intervention unless the location is “normal” for that patient/client. For example, if a treatment was administered in a patient recreation area, or if advice was given to a patient/client over the telephone, the record should indicate this.
Point of Care Testing
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.
RTs are required to document according to the same professional standards, whether they are treating an in-patient or out-patient. Whether you are taking an ABG in your hospital’s ICU or in your hospital’s outpatient PFT clinic, all of the standards for documentation must be met.
Practicing in the Community
RTs work in a wide variety of practice settings (e.g., doctor’s offices, dental offices, patient education clinics). Regardless of the practice setting, all RTs are accountable for ensuring that all patient/client contacts are documented according to the required professional standards.
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.
V. Why it Happened
The reason or purpose of the intervention should be included in your documentation. Is the intervention a routine visit; as a result of diagnostic tests; to perform diagnostic testing; as a result of an improvement or deterioration in status; or as a result of a medical directive or an RT protocol? Why did you do what you did? If you’re administering a plan of treatment, it would be appropriate to document why the plan of treatment is being initiated the first time and then only make note of “why” if there’s a specific reason to.
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.
Table 1: Examples of Objective vs. Subjective Documentation
|“the patient was crying”||“the patient was sad”|
|“the patient complained of SOBOE|
and was dyspneic with movement”
|“the patient appeared
|“the treatment was not performed|
because…” list the facts
|“this treatment was not in the
best interest of the patient”
|“I informed Dr. Smith by|
telephone of the changes to the
patient’s status as charted in the
|“the doctor is aware”|
Patients/clients and/or their family members have a legal right to access medical records. Therefore, any personal judgements and opinions that an RT might have should not be part of a PHR.
VI. The Result of What Happened
It’s essential that the outcome of every intervention is captured in the PHR. This gives the entire health care team the ability to know what was done and whether the intended therapy goals were met. This information is invaluable in guiding future treatment decisions, and should include such information as:
the result of the intervention;
An RT has been asked to initiate BiPAP on a patient/client who has elevated PaCO2 levels and is nearing the end of a terminal illness. Both the patient and the RT agree to the treatment plan, although the RT feels the benefits of the therapy will be limited. When documenting, it is important to include not only the intervention itself, but also the treatment goal(s) and plan (e.g., how long the patient/client will remain on BiPAP; when the treatment plan will be reassessed; how and when the RT plans to follow up on the patient/client’s progress).
VII. By whom it happened
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.
If using a paper-based signature record, initials and professional designation are sufficient. If a signature record is not used, a printed name should be included if a signature is not easily legible.
Co-signing Documentation when Supervising Others
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.
An RT student in their final clinical rotation is performing an arterial blood gas under “general” supervision (i.e. the supervising RT is not physically present and observing the activity). Since the activity is being done under “general” supervision in this situation (not under direct supervision), the student must sign their own documentation and the RRT should not co-sign.
The CRTO recognizes that common RT flowsheets used in critical care areas (such as ICU and NICU) may not provide enough space for Members to explicitly state that the activity was done under direct supervision. We suggest that you may want to reference somewhere in the patient/client health record that where two (2) initials are present, this indicates that direct supervision took place.
General (indirect) Supervision requires that the supervising RRT is ready and available to be “personally present” within 10 minutes if assistance is required. (CRTO Supervision Policy)
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.
Documenting a Disagreement With An Order Or Plan of Treatment
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.
Withdrawal of Care/Services Due to Abuse or Violence
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;
For more information and scenarios regarding the ethics of withdrawing or withholding Respiratory Therapy care/ services, please refer to the CRTO document A Commitment to Ethical Practice.
It is important that you DO NOT document for someone else. There may be instances when it becomes necessary to document observations on care provided by others, (e.g., a family member witnesses a patient/client fall). It must be clear who had the first-hand knowledge of the event, who performed the activity/intervention and who recorded the activity.
Agents (of the Health Information Custodians): defined in the Health Care Consent Act (HCCA) in relation to a health information custodian, as “…a person that, with the authorization of the custodian, acts for or on behalf of the custodian in respect of personal health information for the purposes of the custodian…”
CRTO Member: A Respiratory Therapist who is registered with the CRTO; including Graduate Respiratory Therapists (GRT), Practical (Limited) Respiratory Therapists (PRT) and Registered Respiratory Therapists (RRT).
Charting By Exception (CBE): a charting system used in patient/client health records. CBE requires a detailed plan of care map, and includes flowsheets, graphic records and progress notes that may take the format of SOAP/SOAPIE(R) (Subjective, Objective Data, Assessment, Plan, Intervention, Evaluation, and Revision).
Focus Charting System: a charting system which includes flow-sheets, checklists and progress notes that take the format of DARP (Data, Action/Analysis, Response, and Plan).
Health Information Custodian (HIC): defined in the HCCA as “…a person or organization described in one of the following paragraphs who has custody or control of personal health information…”.
Medical Directive: a medical order for a range of patient/clients who meet certain conditions. The medical directive is the order and should therefore meet the criteria for a valid medical order.
Narrative Charting: when data is recorded as progress notes, supplemented with plan of care flow sheets.
Personal Health Records (PHR): the record kept by HICs who provide health care and may be in either a paper-based or computerized format.
Primary Care: including, but not limited, to Family Health Teams, Community Health Centres, various agencies, such as the Canadian Mental Health Agency.
Problem-Oriented Charting (POHR): charting system which includes a plan of care, problem list and progress notes/discharge plans which take the format of “SOAP/SOAPIE” (Subjective data, Objective data, Assessment data, Plan, Intervention and Evaluation).
- Cavoukian, A. (2009). Circle of care: Sharing personal health information for health care purposes. Retrieved from Information and Privacy Commissioner Ontario website: https://www.ipc.on.ca/images/Resources/circle-care.pdf
- College of Nurses of Ontario. (2008). Documentation. Practice Standard. Retrieved from http://www.cno.org/Global/docs/prac/41001_documentation.pdf
- College of Physicians and Surgeons of Ontario. (2020). Medical records. Policy Statement (#4 – 12). Retrieved from https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Medical-Records-Documentation
- College of Physiotherapists of Ontario. (2017). Record Keeping Standard. Retrieved from https://www.collegept.org/rules-and-resources/record-keeping
- Cox, K., Moghaddam, N., Almack, K. et al. Is it recorded in the notes? Documentation of end-of-life care and preferred place to die discussions in the final weeks of life. BMC Palliat Care 10, 18 (2011). https://doi.org/10.1186/1472-684X-10-18
- Paterson, A. M. (2013). Medical Record as a Legal Document Part 2: Meeting the Standards. Journal of Legal Nurse Consulting, 24(1), 4-10. Retrieved from http://www.aalnc.org/?page=JLNC