LibGuides: Clinical Standardization: Clinical Documentation

Improving Clinical Documentation

Documentation should be both an outcome and an integral part of providing high quality care.

Clinical documentation should:

Be interprofessional
Be developed through healthcare practitioner/learner engagement
Reflect best practice guidelines
Facilitate ease of communication between providers and patients

An essential guide to clinical documentation improvement
Jamal, A., Grant, C., & Myrick, K. (2018). An essential guide to clinical documentation improvement. Retrieved December 22, 2020.

Interprofessional Documentation

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:

Participation of multiple healthcare providers from different professional backgrounds
Effective interprofessional collaboration
Delivering high quality care across settings
Including patients, their families, caregivers and communities in health care planning and decision making

A recent systematic review found electronic nursing documentation interventions result in time efficiencies and fewer documentation errors (McCarthy, Fitzgerald, Shea et al., 2018).

Examples of where interprofessional documentation is currently being used:

Mental Health & Addictions (IWK)
Acute care medicine program (Nova Scotia Health)
Orthopedic Assessment Clinics and Neurosurgery (Nova Scotia Health)

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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.