Clinical Standardization

Seamless integration of clinical systems to provide collaborative patient-centered care

Improving Clinical Documentation

Documentation should be both an outcome and 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

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

Examples of where interprofessional documentation is currently being used:

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

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 toI WK and  NSHA  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.