Documentation Practices

Policy

Category: General 
Subject: Documentation Practices 
Policy Number: CA.50.01.101
Effective Date: September 24, 2012

POLICY STATEMENT

Wellington-Dufferin-Guelph Public Health (WDGPH) employees must document the services provided to a client/family/community in accordance with WDGPH policy, program specific policies and procedures, standards of professional bodies as applicable, and in accordance with privacy legislation. 

Documentation is any written or electronically stored information about a client that describes the care or service provided to that client. Health records may be paper documents (e.g. client files, evidence books etc.) or electronic documents, such as electronic medical records, faxes, e-mails, audio or video tapes and images. Through documentation, employees record their observations, assessments, decisions, actions and outcomes. Documentation is central to the provision of safe, effective and ethical care and service.

The purposes of documentation are to support:

  • Communication;
  • Accountability;
  • Legislative requirements;
  • Quality improvement;
  • Research;
  • Funding; and
  • Resource management.

Agency and program specific documentation policies and procedures comply with the privacy legislations with respect to the collection, use, disclosure and disposal of confidential information.

SCOPE

This policy applies to all employees who are directly or indirectly (i.e. consulting participating or supporting a healthcare professional) providing a WDGPH service to a client.

PRINCIPLES OF DOCUMENTATION:

A client is an individual or a group who receives direct services by WDGPH employee(s).  A client may be an individual, family, substitute decision maker, group, premise, workplace, business, organization, community, or population as well as other health professionals who are requesting consultation /advice. “Client” is defined by program specific policies relevant to the service provided.  The following are examples of clients:

An individual client is:

  • A person;
  • A family; or
  • A premise – multiple names included.

A Group client is identified as two or more clients for example:

  • Groups of  long-term care facilities or schools;
  • Classes or programs  such as prenatal education classes;
  • Coalitions, community/external committees; or
  • Consultants, service providers and partners.

Types of Services Documented:

Documentation reflects both direct service and indirect service. Direct service to individuals involves advice, care or services provided to an individual, an individual within a group, groups, communities or populations. Examples of direct service include:

  • Face to face interactions;
  • Telephone interactions;
  • Information mailed to clients;
  • E-mails;
  • Voicemails; and
  • Information collected, and/or recommendations made by non-regulated healthcare professionals, support employees or administrative employees to contact a professional healthcare provider.

Indirect service involves consultation. Examples of indirect service include:

  • Program development, project work, community development; and
  • Consultation with other professionals about confidential or personal health information

Minimum documentation requirements:

Staff members must maintain documentation that is:

  • A complete record of service or care provided;
  • Clear, concise and comprehensive;
  • Accurate, true and honest;
  • Relevant;
  • Confidential;
  • Client-focused;
  • Timely and completed only during or after providing service;
  • Chronological;
  • Legible and non-erasable (written records);
  • Entered following WDGPH policy and procedure CA.59.01.101 Electronic Record Retention and Destruction;
  • Permanent;
  • Retrievable; and
  • Completed using forms, methods, systems provided the WDGPH and/or programs.

DEFINITIONS

Anonymous clients – are clients who provide information to WDGPH with no identifying information appearing in the record (e.g. hotlines, intake, etc.)

Record- Any documentation related to the provision of service provided in a variety of formats; such as:  verbally, print form, film, electronically or any other means.

A transitory note – is information recorded on sticky notes, pieces of scrap paper, or notebooks   as an interim, temporary measure to capture information that will be transcribed into the official record. Transitory notes are not considered stand alone, official documentation and are:

  • Created solely for the convenience of reference; and
  • Required solely for the completion of a routine action, or the preparation of the official document/ record.

Examples include sticky notes, memos and written messages which are considered to have only immediate or short term value and can be destroyed immediately when information has been transcribed and the note is no longer required.

Agency Employees - Includes all employees providing services to clients on behalf of the Agency, including professional, management, administrative and, support employees, students and volunteers

REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES

Directors are responsible to:

  • Document according to policy and procedure CA.50.01.101 and CA.50.02.101 Documentation Practices;
  • Ensure program specific policies and procedures are implemented across their Division.
  • Ensure documentation related security breaches are resolved.

Program Managers/Supervisors are responsible to:

  • Document according to policy and procedure CA.50.01.101 and CA.50.02.101 Documentation Practices;
  • Train program employees on policy and procedure CA.50.01.101 and CA.50.02.101 Documentation Practices;
  • Assist  employees in interpreting and applying policy and procedure CA.50.01.101 and CA.50.02.101 Documentation Practices to their practice;
  • Implement an auditing practice for documentation; and
  • Inform the Director and/or Chief Privacy Officer of any possible documentation related security breaches.

Employees are responsible to:

  • Document according to policy and procedure CA.50.01.101 and CA.50.02.101 Documentation Practices;
  • Ensure documentation meets professional standards of practice;
  • Follow all program specific policies and procedures and/or guidelines for documentation;
  • Consult with Managers if clarification or interpretation is required;
  • Maintain security of all confidential information in their possession , i.e. personal, personal health information and confidential records; and
  • Follow privacy legislation and WDGPH’s policies for protecting confidential information. 

SECURITY:

Employees will follow privacy legislation and WDGPH’s policies for protecting confidential information. In addition to policy and procedure CA.50.01.101 and CA.50.02.101 Documentation Practices, employees who are members of a College governed by the Regulated Health Professions Act, 1991 must also comply with the documentation standards of their College.

REFERENCES AND RELATED POLICIES AND PROCEDURES:

Corresponding Procedure:  CA.50.02.101 Documentation Practices

  • CA.50.01.100  Abbreviations and Acronyms (policy pending)
  • CA.54.01.103  Email Use (policy pending)
  • CA.58.01.101  MFIPPA
  • CA.58.01.102  PHIPA
  • CA.59.01.101  Electronic Record Retention and Destruction (policy pending)
  • Health Promotion and Protection Act (HPPA)
  • Municipal Freedom of Information and Protection of Privacy Act (MFIPPA)
  • Personal Health Information and Protection Act (PHIPA )
  • Regulated Health Professionals Act 1991
  • Chief Information Privacy Office of Ontario- Guideline Government of Ontario Common Records Series
  • College of Audiologists and Speech-language Pathologists of Ontario. Proposed Regulation for Records (April 1996). http://www.caslpo.com
  • College of Dental Hygienists of Ontario. Prescribed Records Regulation, 2005 (March 05) www.cdho.org
  • College of Dietitians of Ontario. Draft Proposed Regulations regarding “Records Relating to Members Practice. http://www.cdo.on.ca
  • College of Nurses of Ontario, 2002. Nursing Documentation Standards, (Revised) Toronto, Ontario, Pub # 41001. www.CNO.org
  • College of Physicians and Surgeons of Ontariohttp://www.cpso.on.ca/Policies/policy.htm
  • Royal College of Dental Surgeons of Ontario-. Dental Recordkeeping Guidelines
  • www.rcdso.org/pdf/guidelines/dentalrecordkeep.pdf

APPROVED BY

Carole Desmeules    


Procedure

Category: General
Subject: Documentation Practices 
Procedure Number: CA.50.02.101
Effective Date: September 24, 2012

PROCEDURE

Documentation:

  • Must be current, clear, concise and comprehensive;
  • Contain relevant and meaningful information;
  • May include both objective and subjective data, where relevant;
  • Must be kept confidential;
  • Corrections, changes or additions must follow guidelines;
  • Records must not be altered; and
  • Only WDGPH abbreviations and acronyms shall be used according to policy CA.50.01.100 Abbreviations and Acronyms.

Date and Time format:

  • The date should be written in alpha-numeric format (e.g. 31 Jan, 2011 or Jan 31, 2011). It is acceptable to have numeric dates in situations where electronic forms generate the date (e.g. ISCIS, IPHIS etc).
  • If the date and time of interaction is different than the date of documentation, both dates need to be recorded.
  • The 24-hour clock or the 12-hour plus a.m./p.m. should be used.

Signatures:

  • All entries in records must be signed and include professional designation.
  • Insert the date of documentation with the writer’s signature.
  • Regulated health professionals’ signatures must be the same as the name printed on their respective college annual membership renewal card.
  • A master list will be maintained that identifies the staff’s full name, designation, full signature and initials to clarify accountability.
  • Students not licensed or certified require their documentation to be co-signed by their mentor/preceptor according to College standards where applicable.

Corrections, Changes or Additions:

  • When making a correction, change or addition the content must be clearly indicated. If a change is being made to the original entry at a later time, clearly indicate date and time of new entry.
  • Any missed, erroneous or late entries must be documented at the next available entry space in the record, clearly indicating what service was provided. Write “late entry” or “error” and “date and time” of corrected documentation and the original interaction, and where appropriate reason for changed entry.
  • The original information must remain visible or retrievable (e.g. draw a line through errors made in recording and indicate “error” and initials).
  • White out or correction tape cannot be used on a client record, or use to alter the records in any way.
  • Refer to program specific guidelines for making corrections, changes or additions in an electronic record.
  • Employees should never delete, modify or alter anyone else’s documentation.

Correspondence and reports:

  • Copies of third party reports should be kept separate but within the record. Any correspondence received should be dated and stamped.

Transitory notes:

Transitory notes that have been recorded on sticky notes, pieces of scrap paper, or notebooks which contain sensitive, confidential information and are of meaningful value (i.e. reflect practice) must be transferred and documented in the official record. Once documented in the official record, the transitory note should be securely destroyed. Examples may include:

  • telephone message slip providing evidence of an individual calling at a certain time and date;
  • self-adhesive note giving you authorization to carry out an activity or providing you with instructions to carry out an activity; and
  • PHI interview notes/PHN rough notes from a home visit.

Note: Transitory notes must be destroyed using secure methods appropriate to their level of sensitivity and or security classification. For example paper records containing personal or personal health information must be securely shredded. Refer to policy CA.59.01.101 Electronic Record Retention and Destruction.

Transitory notes which contain temporary information that has been recorded on sticky notes, pieces of scrap paper, or notebooks and do not contain confidential information or meaningful information that is required in the official documentation should be destroyed immediately when the material is no longer required. Examples include:

  • basic phone messages such as “please return my call,” or “I am on my way”;
  • opened envelopes where the envelope does not provide any necessary additional information such as senders address, date of receipt stamp;
  • self adhesive notes used as reminders to do a task;
  • minor administrative messages such as confirming meeting times.

Telepractice:

When offering healthcare advice, guidance or service over the telephone, documentation of the interaction must follow:

  • CA.50.01.101 and CA.50.02.101 Documentation Practices;
  • Program specific policies/procedures/guidelines; and
  • Professional standards, guidelines or practices recommended by professional associations.

Electronic mail:

  • Emails containing relevant information relating to a client’s case are considered to be written documentation, and should be included in the client’s file.
  • Emails must be professional and consistent, using the file number as part of the subject where available. Since these emails are part of the records of the file it should be referred to in documentation records and placed in file.
  • Refer to policy CA.54.01.106 E-mail Use which outlines the guidelines and procedures for email interactions internally and externally containing personal and/or personal health information.

Record Content:

The content and ordering of a client or service record is detailed in program specific policies and procedures. Documentation of all relevant client interactions is expected to be done in chronological order, and will include the following as relevant/applicable or prescribed within program-specific policy and procedures:

Individual Client:  

  • date, time and location of interaction;
  • date and time  when recorded;
  • name of the provider(s), client, facility or premise involved ;
  • two pieces of identifying information of the client[1];
  • purpose of the interaction;
  • significant communication with family members, significant others[2], substitute decision makers and other care providers;
  • document informed consent where applicable, i.e. sharing of information, consent to treatment or services;
  • all relevant information related to the client that is shared by a third party source (e.g. hospital referral, consultation, etc.) must be documented as part of the record, provided there is client consent or overriding legislation;
  • any medication taken by client, or prescribed by public health;
  • any lab tests prescribed;
  • advice, suggestions or referrals;
  • any follow-up  required;
  • each examination, clinical finding, assessment or inspection relating to the client
  • written or informed consent;
  • any consultations or treatments performed by any other person relating to the client;
  • direct consultations with a peer regarding a specific client must be documented in the client’s file including outcomes, agreed upon plans and names of those involved in the consultation documenting the person’s signature, initials and professional designation;
  • consecutive page numbers on ongoing documentation; and
  • record of any equipment used in the interaction.

There are instances where clients are anonymous. In these instances, record:

  • date of the service;
  • request for anonymity, or reason staff unable to obtain name;
    reason for the service;
    assessment of client needs;
    symptoms;
    advice given;
    recommended follow-up; and
    signature and professional designation will be recorded. 

Group Client: 

  • names of participants if necessary;
  • date: alpha–numeric;
  • brief summary of session- includes topics covered and activities planned;
  • resources;
  • evaluations;
  • a summary of the evaluations with recommendations for improvement;
  • log sheets/database; and
  • any meaningful individual interactions that occurs in the group setting should be documented in the group log sheet as per program specific policies.

Health Promotion, Project/Program Planning:

Documentation related to program or project planning must be documented using the WDGPH approved project planning templates which are available on WDGPH’s intranet, and include at a minimum:

  • goals and objectives;
  • strategies and activities;
  • indicators and outcomes; and
  • budget.

At a minimum, work plans must include:

  • activity and tasks;
  • person responsible;
  • timelines; and
  • resources required.

Final project plans and work plans must be revised and updated quarterly by each staff member. All project plans and work plans must be stored electronically in a clearly labelled folder in the Z: network drive OR in a clearly labelled binder and retained for six years.

All indirect client interactions resulting from project work, activities, events and other applicable tasks must be documented using work plans or project plans.

All indirect client interactions resulting from committees, coalitions and other applicable groups must be documented in minutes. At a minimum, these minutes must include: 

  • name of group;
  • date and time of meeting;
  • individuals present and absent; and
  • discussion items and action items.

It is the responsibility of each individual to review minutes to ensure that the content of the meeting was properly documented. All minutes must be stored electronically in a clearly labelled folder in the Z: network drive or in a clearly labelled binder and retained for two years.

Documentation Audit:

Documentation audits are performed by practitioners within their respective division and under the supervision of Managers. Each Division must set up their own audit process utilizing an Audit Tool that pertains to their area of practice, service delivery and professional standards. All documentation venues (electronic and paper) must be audited at a minimum annually.

[1] Identifying information can be first and last name, date of birth, address, telephone number, postal code, health card number,
[2] Significant other may include, but is not limited to, the person the client identifies as being the most important in his or her life. Examples include spouse, partner, parent, child, sibling or friend. 

REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES

Corresponding Policy:  CA.50.01.101 Documentation Practices

  • CA.50.01.100  Abbreviations and Acronyms (policy pending)
  • CA.54.01.103  Email Use (policy pending)
  • CA.58.01.101  MFIPPA
  • CA.58.01.102  PHIPA
  • CA.59.01.101  Electronic Record Retention and Destruction (policy pending)
  • Health Promotion and Protection Act (HPPA)
  • Municipal Freedom of Information and Protection of Privacy Act (MFIPPA)
  • Personal Health Information and Protection Act (PHIPA )
  • Regulated Health Professionals Act 1991
  • Chief Information Privacy Office of Ontario- Guideline Government of Ontario Common Records Series
  • College of Audiologists and Speech-language Pathologists of Ontario. Proposed Regulation for Records (April 1996). http://www.caslpo.com
  • College of Dental Hygienists of Ontario. Prescribed Records Regulation,2005 (March 05) www.cdho.org
  • College of Dietitians of Ontario. Draft Proposed Regulations regarding “Records Relating to Members Practice. http://www.cdo.on.ca
  • College of Nurses of Ontario, 2002. Nursing Documentation Standards, (Revised) Toronto, Ontario, Pub # 41001. www.CNO.org
  • College of Physicians and Surgeons of Ontariohttp://www.cpso.on.ca/Policies/policy.htm
  • Royal College of Dental Surgeons of Ontario-. Dental Recordkeeping Guidelines
  • www.rcdso.org/pdf/guidelines/dentalrecordkeep.pdf

APPROVED BY

Carole Desmeules