Documentation should be both an outcome and an integral part of providing high quality care.
Clinical documentation should:
Healthcare is transitioning towards interprofessional teams to provide Collaborative Patient Centered Care (CPCC). CPCC occurs when practitioners seek out, integrate and value the input and engagement of patient/client/ family/community partners when designing and implementing care or health services (Nova Scotia Health Authority, 2018). According to the Canadian Interprofessional Health Collaborative (2010), interprofessional collaboration is a key aspect in the provision of CPCC and achieving improved health outcomes.
Documentation is an important component of CPCC that facilitates communication within the interprofessional team.
Interprofessional documentation involves:
Examples of where interprofessional documentation is currently being used:
Canadian Interprofessional Health Collaborative (2010). What is Interprofessional Education? Retrieved July 29, 2019 from https://www.cihc.ca/files/CIHC_Factsheets_IPE_Feb09.pdf.
Healthtech (2019). Clinical documentation methodology [presentation]. Presented to IWK and Nova Scotia Health February 5, 2019.
McCarthy, B., Fitzgerald, S., O’Shea, M., Condon, C., Hartnett-Collins, G., Clancy, M., . . . Savage, E. (2018). Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review. Journal of Nursing Management, 27(3), 491-501. doi:10.1111/jonm.12727.
Nova Scotia Health Authority (2010) Interprofessional Practice & Learning Framework: Quick Reference Guide for Clinical Leaders.