Documentation Guidelines

for Registered Nurses

College of Registered Nurses of Nova Scotia

Documentation Guidelines for Registered Nurses

First printing (1997)
Revisions (2002/2005/2012)
2012, College of Registered Nurses of Nova Scotia
Suite 4005 7071 Bayers Road, Halifax, NS B3L 2C2
[email protected]
www.crnns.ca
All rights reserved. Individual copies of this document may be downloaded from the College website. Portions
of this publication may be reproduced for personal use. Reproduction of this document for other purposes, by
any means, requires permission of the copyright owner.

Table of Contents
Introduction.................................................................................................................................................4
Professional Principles of Documentation...................................................................................................4
Confidentiality.............................................................................................................................................5
Why should RNs document?......................................................................................................................5
Who should document?..............................................................................................................................7
What should RNs document?.....................................................................................................................8
How Should RNs document?....................................................................................................................13
Client Care Provided Through Electronic Means...........................................................................15
When should RNs document?..................................................................................................................17
Conclusion.................................................................................................................................................18
References ................................................................................................................................................19
Glossary of Terms......................................................................................................................................21
Appendices
Appendix A- Legislation affecting Nursing Documentation...........................................................26
Appendix B- Practice Exercise/Responses......................................................................................26

Introduction
Nursing documentation is a vital component of safe, ethical and effective nursing practice, regardless of the
context of practice or whether the documentation is paper-based or electronic. This document is intended
to provide registered nurses (RNs) with guidelines for professional accountability in documentation and to
describe the expectations for nursing documentation in all practice settings, regardless of the method or
storage of that documentation. The intention of the document is to assist the registered nurse to meet their
standards of practice related to documentation.
Registered nurses in Nova Scotia are legally and ethically required to practise nursing in accordance with the
Registered Nurses Act (2006) and Regulations (2006), the Colleges Standards of Practice for Registered Nurses
(2012), Entry- level Competencies (2009) and the Code of Ethics for Registered Nurses (CNA, 2008). According
to the Standards1, each registered nurse is expected to complete written and/or electronic documentation in
a manner that is clear, timely, accurate, comprehensive, legible, chronological, and is reflective of relevant
observations.
Although different documentation systems and technology may be used throughout the province, quality
nursing documentation is expected in every area of care or service delivery and in every setting. Nurses must
be familiar with, and follow, agencies documentation policies, standards and protocols. It is recommended
that the Colleges Documentation Guidelines for Registered Nurses serve as a basis for the development of
agencies policies on nursing documentation. If there are no agency policies in place related to documentation,
it is the professional nurses responsibility to advocate for the creation of policy to support nursing practice. If
despite advocating for the creation of policies, there are still no documentation policies in place, professional
nurses need to use their Standards of Practice, these guidelines and professional judgment to guide practice.

Definition
Documentation is anything written or electronically generated that describes the status of a client or
the care or services given to that client (Perry, A.G., Potter, P.A., 2010). Nursing documentation refers to
written or electronically generated client information obtained through the nursing process (ARNNL, 2010).
Documentation is an integral part of nursing practice and professional patient care rather than something that
takes away from patient care. Documentation is not optional.

Professional Principles of Documentation

Nursing documentation must provide an accurate and honest account of what and when events occurred, as
well as identify who provided the care. Good documentation has six important characteristics. It should be:

factual
accurate
complete
current (timely)
organized
compliant with standards (Potter & Perry,2010 p212).

These core principles of nursing documentation apply to every type of documentation in every practice setting.

2012 Standards of Practice for Registered Nurses Standard 2 Knowledge Based Practice and Competence Indicator 2.6

Confidentiality
Clients have a right to protection of their privacy with respect to the access, storage, retrieval and transmittal
of their records and to receive a copy of their health records for a reasonable fee. The rights of clients and
obligations of public agencies are outlined in Freedom of Information and Protection of Privacy Act (FOIPOP)
and the Personal Health Information Act and often are summarized in agency policies.

Technology does not change

clients rights to privacy of
health information. Whether
documentation is paper-based,
electronic or in any other format,
maintaining
confidentiality
of all information in a health
record is essential, and relates
to access, storage, retrieval
and transmission of a clients
information.

Healthcare professionals should view security of client

documentation as a serious issue. Failure to comply with keeping
records as required, falsifying or furnishing false information and
providing information about a client without consent of the client
or agency administration can constitute professional misconduct
under the Registered Nurses Act (2006).
Documentation, in any format, should be maintained in areas
where the information cannot be easily read by casual observers.
Although nurses often share client information with the healthcare
team, it is important that clients understand that sharing
confidential information with team members occurs only in an
effort to ensure the provision of quality care.

When health records are maintained in a clients home, there is the potential for family members and/or
others (e.g., visitors, guests) to access confidential information. It is important that agencies/facilities have
policies in place outlining who should be able to access the health records and how clients and/or family
members will be made aware of the importance of maintaining confidentiality.

Why should RNs document?

Clear, complete and accurate health records serve many purposes for clients, families, registered nurses and
other care providers. Data from documentation allows for:

Communication and Continuity of Care

Clear, complete and accurate documentation in a health record ensures that all those involved in a
clients care, including the client, have access to information upon which to plan and evaluate their
interventions.
A good test to evaluate whether your documentation is satisfactory is to ask the following question: If
another RN had to step in and take over this assignment, does the record provide sufficient information
for the seamless delivery of safe, competent and ethical care?(CARNA, 2006).
All members of the health care team require accurate information about clients to ensure the
development of an organized comprehensive care plan. The risk of inaccurate or incomplete
documentation is: care that is fragmented, tasks that are repeated and therapies which could be
delayed or omitted (Perry & Potter, 2012, p209).

Quality Improvement/Assurance and Risk Management

Clear, complete and accurate nursing documentation facilitates quality improvement initiatives and risk
management analysis for clients, staff and organizations.
Through chart audits and performance reviews documentation is used to evaluate quality of services
and appropriateness of care.

Establishes Professional Accountability

Documentation is a valuable method of demonstrating that nursing knowledge, judgment and skills
have been applied within a nurse-client relationship in accordance with the Standards of Practice for
Registered Nurses.
Registered nurses are expected to follow the Standards of Practice for Registered Nurses (2011) and
Code of Ethics for Registered Nurses (2008) when documenting information related to the health status
of clients, related situations/circumstances, and care provided.
Standard 2, Knowledge-Based Practice and Competence, in particular, Indicator 2.6, speaks to the
registered nurses professional accountability related to documentation practices.

Legal Reasons
The clients record is a legal document and can be used as evidence in a court of law or in a professional
conduct proceeding.
Documentation should provide a chronological record of events in client care and delivery of services.
Courts may use the health record to reconstruct events, establish time and dates, refresh ones
memory and to substantiate and/or resolve conflicts in testimony (CNPS, 2009).

Funding and Resource Management

Documentation can be used by administrators to support funding and resource management.
Through chart audits and performance reviews documentation is used to identify the type and amount
of services required and provided as well as the efficiency and effectiveness of those services.
Workload measurements and/or client classification systems, derived as a consequence of client
documentation, are used by some agencies to help determine the allocation of staff and/or funding.

Expanding the Science of Nursing

Health records serve as a valuable and major source of data for nursing and health related research.
Data obtained from health records is also used in health research to assess nursing interventions,
evaluate client outcomes, and determine the efficiency and effectiveness of care. The type of research
made possible through the information in health records can enable nurses to further improve nursing
practice.

Who should document?

First hand knowledge only
Legislation and Standards of Practice of the profession require nurses to document the care they provide
demonstrating accountability for their actions and decisions. First hand knowledge means the professional
who is doing the recording is the same individual who provided the care. In situations where two or more
people provide care or services, the RN who has the primary assignment is expected to document the
assessment, interventions and client response, noting as necessary the role of other care providers. However,
the second provider is expected to review the documentation and make an additional entry if necessary.
If the client is receiving services from two or more different agencies or departments that have separate
records (i.e., Health and Justice) it is important that the RN record the care s/he provided in all relevant
documents. Agency policy must clearly articulate where documentation is to occur on the health record to
ensure consistency.
There may be times when it is not possible to record first hand so the information must be recorded by a third
party. If the information is recorded as reported from another source the RN must use quotation marks to
identify that source. It may also be necessary to record why third party documentation occurred. Even when
third party documentation occurs it may be necessary for the registered nurse to document her/his nursing
care of the patient.
The following are situations in which third party recording or
additional documentation may occur:

Self-employed nurses must adopt

a documentation system and
develop appropriate policies,
including those related to the
storage, retrieval and retention
of health records.
The Colleges Guide for SelfEmployed Practice provides
direction on the documentation
requirements for self-employed
nurses and is available by
contacting the College or visiting
the College website at www.
crnns.ca/SelfEmployed

Auxiliary Staff
Agencies need to ensure that all care providers demonstrate
necessary competence with regard to documentation. To ensure
accuracy of information, auxiliary staff should document the care
they provide and observations they make. In some agencies,
unregulated care providers (UCP) are permitted to document care
in the permanent health record (electronically and paper-based). In
other agencies, however, UCPs may have access only to notes not
contained on the permanent client health record. Agency policies
need to indicate who may document in client health records and
what practice is to be followed. Although not recommended, if
an agencys policy specifies that auxiliary staff are not to record
information, registered nurses should document the reports given
to them by auxiliary personnel, including the individuals name and
status. If possible, auxiliary staff should read and initial (if using a
paper-based system) documentation related to care they provided.

Designated Recorder
In situations where it is not practical for safety reasons for the professional implementing the care to
document, it is acceptable practice to have a designated recorder. An example may be during procedural
events in areas such as the emergency department, operating room or the delivery room where the nurse
providing care cannot physically document because of sterility and/or because safety of the client could be
7

compromised if the nurse was to leave the patient to document. Another example is a Code Blue situation
where the health professionals providing the care have limited time to document. Organizational policy should
support the practice of designated recorders in these situations.

Client or Family
In some settings it may be acceptable practice that a client, family member and/or sitter to document
observations and care. Some examples include a mother documenting newborn intake and output or a client
performing peritoneal dialysis documenting information about exchanges in their home chart. Agency policy
should outline what should be documented and by whom, as well as the responsibilities of nurses with respect
to the documentation.

Students
Students are learners and not employees. All students are expected to document the care they provide in
accordance with agency and academic policies. Co-signing notes written by students is not acceptable and may
add a level of accountability which the RN would not otherwise incur (SRNA, 2011). It may be necessary for the
RN preceptor to document their own assessment, interventions and evaluations. The need for this extra level
of documentation must be based within agency policy and upon professional judgment. For example, if a client
developed an acute or complex problem the RN preceptor should document her/his assessment and response
to the problem in addition to the students documentation (SRNA, 2011).

Co-signing and Countersigning Entries

Co-signing refers to a second or confirming signature on a witnessed event or activity (ARNNL, 2010). Cosigning entries made by other care providers is not a standard of practice and, when poorly defined, can
blur accountability (CNO, 2003, p10). If two nurses are involved in an assessment or the delivery of care,
both nurses should document, according to agency policy. Agency policies should clearly describe how
documentation should be completed when two nurses are required to be involved in an aspect of care. For
example, if two registered nurses are required to hang a unit of packed-cells, and both must sign the health
record, the intent of a co-signature should be clearly stated in policy. In this case, agency policy would likely
indicate that the co-signature is confirmation that the nurse (co-signee) witnessed that the correct unit was
given to the correct client. Co-signing implies shared accountability. It is imperative that the person co-signing
actually witnessed or participated in the event (SRNA, 2011).
Countersigning is defined as a second or confirming signature on a previously signed document, a blind
signature which is not witnessed (SRNA, 2011). This is not best practice and is generally not supported, but
may be effectively utilized as a quality control process. For example, an RN reviews a chart to determine if all
the orders are accurately transcribed or all required interventions are completed. Agency policy and procedure
should be in place to support this practice. Countersigning does not imply that the second person provided the
service but it does imply that the person approved or verified that the service or record was completed.

What should RNs document?

All Aspects of the Nursing Process
Documentation which reflects the nursing process demonstrates that an RN has fulfilled her/his duty of
care. It also demonstrates the unique contribution of nursing to the care of clients. Nurses should record
data collected through all aspects of the nursing process. As a general rule, any information that is clinically
significant should be documented.
8

To determine what is essential to document, for each episode of care or service the health record should
contain:

a clear, concise statement of client status (including: physical, psychological, spiritual)

relevant assessment data (include client/family comments as appropriate)
all ongoing monitoring and communications
the care/service provided (all interventions, including advocacy, counseling, consultation and teaching)
an evaluation of outcomes, including the clients response and plans for follow up
discharge planning.

Failure to document evaluation is a common deficiency in charting. It is imperative to demonstrate the

effectiveness of care/services. An RN should document answers to the following questions as appropriate:
What were the client outcomes? What additional nursing actions were implemented as consequence of client
outcomes? For example, did the vital signs stabilize? Did the pain subside? If not, what was the action?

Plan of Care
Effective client-focused documentation should also include a plan of care. A plan of care is a written outline
of care for individual clients and is part of the permanent record. The plan of care must be clear to everyone
reading the chart. Effective plans of care must be up-to-date and useful to meet the needs and wishes of
individual clients. If a standardized plan of care format (e.g., care maps, clinical pathways) is not used, the
nurse should ensure that her/his notes identify a plan of care for each assigned client.

Admission, Transfer, Transport and Discharge Information

Accurate and concise documentation on admission, transfer, transport and discharge provides baseline data
for subsequent care and follow up. Agency policy should identify expectations on recording communication
between practitioners when clients care is transferred. Nursing documentation should reflect information on
the clients status at discharge, any instructions provided (verbal and written), arrangements for follow-up care
and evidence of the clients understanding, and family involvement as appropriate.

Client Education
RNs provide a wide range of client education on a daily basis. Accurate documentation of this education is
essential to enable communication and continuity of what has been taught. Lack of documentation about
client education diminishes this important aspect of care. The following aspects of client education should be
documented in the health record:

both formal (planned) and informal (unplanned) teaching

materials used to educate
method of teaching (written, visual, verbal, auditory and instructional aids)
involvement of patient and/or family
evaluation of teaching objectives with validation of client comprehension and learning
any follow up required.

Risk Taking Behaviours

RNs are held accountable to the Code of Ethics For Registered Nurses (2008) in which the nurse has an ethical
responsibility to respect a clients informed choice which includes choices related to lifestyle and treatment,
which may be risky to their overall health (ARNNL, 2010). The nurse must document the objective data related
to the risk taking behaviors and should be cautious as to not place a value judgment on the behaviors. The
nurse should also document her/his response to the risk taking behavior and any education they provide
related to the potential consequences of the behavior. It is not acceptable to document the patient as noncompliant. Instead, the nurse should document the objective data that describe this behavior. If the risk taking
behavior results in a situation in which mandatory reporting must occur, such as child abuse, the RN is required
to follow the legislation and document appropriately. Examples of risk taking behaviors include (ARNNL, 2010):

eating foods identified as a dietary restriction

threatening self-harm
ambulating when bed rest is advised
missing follow-up appointments
leaving against medical advice
refusing or abusing medications and/or illicit drugs
tampering with medical equipment.

Incident Reports
An incident is an event which is not consistent with the routine operations of the unit or of client care (Perry
and Potter, 2010). Examples of incidents include patient falls, medication errors, needle stick injuries, or any
circumstances that places clients or staff at risk of injury. Incidents are generally recorded in two places, in the
clients medical record and in an incident report, which is separate from the chart.
Documentation in the chart is used to ensure continuity in client care and should be accurate, concise,
factual, unbiased and recorded by the person who witnessed the event. The nurse should avoid using the
words error, incident or accident in the documentation. It is recommended the nurse first document an
incident in the health record to ensure continuity and completeness, and then complete an incident report in
accordance with facility policies and procedures (Grant & Ashman, 1997).
Incident reports (also called occurrence reports) are separate from the
patient record and are used by organizations for risk management, to
track trends in systems and client care and to justify changes to policy,
procedure and/or equipment. Information included in an occurrence/
incident report is similar to the information included in a clients health
record, however, the incident/occurrence report would also include
additional information with respect to the particular incident (e.g., a
door was broken or this was the fourth such occurrence this week).
Information recorded is not directly related to the care of the client.
Agency policy should clearly describe processes necessary to complete an
incident/occurrence report

10

The purpose of a health

record and occurrence/
incident report differs.
Therefore, for the sake
of clarification, the nurse
should avoid documenting
refer to incident report
in a clients health record.

Medication Administration
Agencies should have specific policies and procedures related to documentation of medication administration.
The general requirements for this type of documentation include:

Date
Actual time medications are administrated
Names of medications
Routes of medications
Sites of administration when appropriate
Dosage administered
Nurses signature/designation

For more information about

Medication
Administration
see the Colleges Medication
Guidelines for Registered Nurses
(www.crnns.ca/documents/
MedicatonGuidelines2011.pdf)

If signatures are used, a master list matching the caregivers initials

with a signature and designation is to be maintained in the health
record. Each healthcare provider (e.g., respiratory therapists,
physiotherapists) should sign for the medications they administer,
except in emergency situations. In emergency situations, registered
nurses may sign for medications administered by other healthcare
providers as long as this is supported by agency policy (see CoSigning, p8).
As part of the nursing process it is important that preadministration assessment data and post-administration evaluation
data should be documented as warranted by the classification of
medication or a clients physical/mental condition.

Verbal Orders and Telephone Orders

The expectation is that authorized prescribers will write
medication orders whenever possible. However, registered nurses
can accept verbal medication orders from authorized prescribers
(either face-to-face or by telephone) when it is in the best interest
of a client and there are no reasonable alternatives. Situations in
which verbal orders would be considered acceptable include:
urgent or emergency situations when it is impractical for a
prescriber to interrupt client care and write the medication
order
when a prescriber is not present and direction is urgently
required by a registered nurse to provide appropriate client
care.
Authorized prescribers should review and countersign verbal
orders as soon as reasonably possible or within the timeframe
indicated in an agencys policy. To ensure that a verbal or
telephone medication order is complete, registered nurses should
check for the following:
11

Guidelines for Taking/

Recording Telephone Orders
Write down the time and date
on the physicians order sheet.
Write down the order exactly
as given by the physician.
Read the order back to the
physician to ensure it is
accurately recorded.
Record the physicians name
on the order sheet, state
telephone order, print your
name and sign the entry, along
with your designation (e.g.,
RN).

clients name
medication name
dosage form (e.g., tablet, inhalant)
route of administration
exact strength of concentration
dose (in unit of measurement)
frequency of administration
quantity and duration
purpose or indication for the medication (i.e., appropriate for clients treatment plan)
prescribers name and designation.

When prescribers transmit medication orders via the telephone they generally do not have the benefit of
conducting direct assessments of clients conditions and, therefore, base their decisions solely on a registered
nurses assessment of the clients receiving the medications.
Comprehensive documentation of RNs assessments can reduce the likelihood of errors, however, errors can
still occur as a result of poor communications or inaccurate transcriptions. Since negative client outcomes can
result from these types of errors, telephone orders, and verbal orders are actually discouraged.

Collaboration with other Health Care Professionals

There is a current trend toward interdisciplinary practice which is supported through the Model of Care
Initiative in Nova Scotia (MOCINS). Creating interdisciplinary communication and documentation is crucial
in developing a strong interdisciplinary practice (Harper, 2007). This way of documenting is intended to
eliminate duplication, enhance efficient use of time and enrich client outcomes through team collaboration.
Collaborative documentation enables healthcare professionals of all disciplines to share the same
documentation tools. Examples of such tools are clinical pathways which reflect interdisciplinary care and
integrated, interdisciplinary patient progress notes.
Registered nurses need to ensure their documentation within an interdisciplinary tool accurately reflects their
unique contribution of nursing to the care of clients. Nurses should not simply sign off the flow sheet or care
map if they have not contributed to the clients care. Signing off the chart implies you have provided care that
is documented and you will be held accountable for the care that was provided.
When nurses collaborate with members of the interdisciplinary team and develop and/or modify the plan of
care based on the collaboration, they should document the following:

date and time of the contact

name(s) of the people involved in the collaboration
information provided to or by healthcare providers
responses from healthcare providers
orders/interventions resulting from the collaboration
the agreed upon plan of action
anticipated outcomes.

For example, if a nurse seeks clarification from a physiotherapist related to mobilization of a patient the
nurse should record the reason for seeking clarification, the name of the healthcare provider providing the
clarification, the action s/he took as the RN, and the expected outcome.

12

Date, Time, Signature and Designation

Documentation in the health record usually begins with date and time and ends with the recorders signature
and designation. Signatures and initials need to be identifiable and follow specific agency policy. Personal
initials can only be used if a master list matching the caregivers initials with a signature and designation is
maintained in the health record.
Agency policy needs to support the method in which date and time is documented. For example, is a 24-hour
or 12-hour clock used and what consistent written format does the date follow? A consistent timepiece should
be used to record time (e.g., cardiac monitor). If you are unable to use this timepiece your documentation
should reflect what you are using to record time.

How Should RNs document?

Clear, Concise, Unbiased and Accurate
Objectivity vs Subjectivity
Objectivity means expressing or dealing with facts or conditions as perceived without distortion by personal
feelings, prejudices, or interpretations (Merriam-Webster Online, 2012). Objective data is observed (e.g.,
crying, swelling, bleeding) or measured (e.g., temperature, blood pressure) and includes interventions, actions
or procedures as well as a clients response.
Subjectivity is characteristic of or belonging to reality as perceived rather than as independent of mind
(Merriam-Webster Online, 2012). Subjective data may include statements or feedback from a client as well as
from family members or a friend.
Documentation should include objective statements related to the nursing process. At times it may be
necessary to include subjective statements in the documentation to enhance the understanding of the clients
care. When documenting subjective information provide accurate examples of what was said using quotes
appropriately along with identification of the individual who made a particular statement. For example, client
states, I am pain-free today or I understood the information provided.

Avoid generalizations
Avoid generalizations and vague phrases or expressions such as status unchanged, assessment done, had
a good day, slept well, up and about. Such vague statements are conclusions without supported facts.
Be specific and use complete, precise descriptions of care. The use of words such as appears, seems, or
apparently is not acceptable when used without supporting factual information because they suggest that
a nurse did not know the facts and demonstrates uncertainty. An exception may be when the supposed fact
cannot be verified. For example, appears to be sleeping, may be appropriate as the only means of verification
would be to wake the client and ask if s/he was actually asleep.

Avoid bias and labels

Do not document value judgments or unfounded conclusions; document only conclusions that can be
supported by data. It is not acceptable for RNs to make value judgments or culturally insensitive comments.
These comments might suggest or imply a dislike for a client, which could be interpreted to mean that the
care provided was substandard (ARNNL, 2010). Select neutral terminology or describe observed behaviors. For
example, rather than stating that the client was drunk it would be correct to state, noted an odor of alcohol
13

and speech was slurred. Instead of noting, client is aggressive it would be correct to state, client has been
shouting and using obscene language. Write each entry with the knowledge that the client has a right to read
their own chart and keep in mind you should only document what can be verified (ARNNL, 2010).

Legibility and Spelling

Correct spelling and legibility of nursing documentation demonstrates a level of competency and attention
to detail. Misspelled words and or illegible entries can result in misinterpretation of information and could
result in client harm. Some spelling errors can result in serious treatment errors. For example, the names of
certain medications, such as digitoxin and digoxin or morphine
and hydromorphone, are similar and must be transcribed carefully
Try not to change pens while
to ensure that the client receives the right medication (Perry and
Potter, 2010).
writing an entry of an event as
All entries in a paper-based system should be written legibly using
black ink, or in accordance with agency policy. The use of black
ink is best for optical scanning technology, which is used in many
clinical areas across Nova Scotia. Never use pencil, gel pens, or
colored highlighters as they are not permanent, can be erased
or changed and do not photocopy or scan readily for storage
purposes. Also, do not use colored paper as information recorded
may not be legible when scanned or photocopied.

this may give the impression that

the entry was not completed in
its entirety at one time. If you
must change pens, document
the reason why.

Blank (White) Space

There should be no blank or white space in paper-based documents as this presents an opportunity for others
to add information unbeknownst to the original author. Agency policy should support nursing documentation
that does not allow white space to occur. An accepted practice is to draw a single line completely through
the white space, including before and after your signature. Fill in all blocks or spaces on flow sheets with the
agency policy approved symbol/comment (e.g. check mark, initials, n/a or X mark). The use of ditto () marks
to indicate repetition of information is unsafe and inappropriate and leaves excess white space (ARNNL, 2010),

Abbreviation, Symbols and Acronyms

The use of abbreviations, symbols or acronyms can be an efficient form of documentation if their meaning is
well understood by everyone. Abbreviations and symbols that are obscure, obsolete, poorly defined or have
multiple meanings can lead to errors, cause confusion and waste time. Use only those abbreviations, symbols
and acronyms that are on a current agency-approved list or an agency approved reference text. Many agencies
today are referring to the list of unsafe abbreviations developed by the Institute of Safe Medication Practice
(http://www.ismp.org/tools/errorproneabbreviations.pdf) in their policy on abbreviation, symbols and
acronyms.
If there is neither an agency-approved list nor an approved reference text, widely understood abbreviations
may be used in a single health record entry when the meaning is spelled out immediately after the
abbreviations first appearance in that entry. For example, a legend on a flow sheet depicting P as poorly,
R as restless, and S as sound.

14

Mistaken Entry/Errors and Changes/Additions

Inaccuracies in documentation can result in inappropriate care
decisions and client injury. Errors must be corrected according to
agency policy. The content in question must remain clearly visible or
retrievable so that the purpose and content of the correction is clearly
understood. If an error occurs in paper-based documentation, do not
make entries between lines, do not remove anything (e.g., monitor
strips, lab reports, requisitions, checklists), and do not erase or use
correction products, stickers or felt pens to hide or obliterate an error.
Also, under no circumstance should chart pages or entries be recopied because of a documentation error. If information is difficult to
read, add pertinent information in a note to chart or note to file.

Failing to correct an error

appropriately (according to
agency policy) or correcting
or modifying anothers
documentation may be
interpreted as falsification of
a record. Falsifying records
is considered professional
misconduct according to
the definition under Section
2(as)(ix) of the Registered
Nurses Act (2006)

Agency policy should guide nurses to the accepted means of

correcting errors. A generally accepted practice to correct an error in a
paper-based system is to cross through the word(s) with a single line,
above the line write mistaken entry and insert your initials, along
with the date and time the correction was made and enter the correct
information.

To protect the integrity of the health record, changes or additions need to be carefully documented. Never
remove pages. A client alternate decision maker, or another care provider, may request changes or additions to
documentation. When the nurse who completed the original documentation is informed of such a request
s/he should refer to agency policy.

Client Care Provided Through Electronic Means

Today in Nova Scotia, many agencies have moved towards
electronic means of providing many aspects of care. From entering
requests for tests and consultations to reporting of diagnostics
testing, to the documentation of care provided, electronic
documentation is part of the everyday care of clients.
Online nursing documentation is defined as a technology that
automates the capture of clinical care data. This can include
assessment data, clinical findings, nursing plans of care, nursing
interventions (along with results), patient progress toward goals,
critical pathways, medication administration, risk assessments,
discharge planning, patient education and more (Kirkley &
Renwick, 2003, p647). Electronic documentation of care can also
include, but is not limited to, faxes, e-mail and/or telenursing.
There are many benefits to electronic documentation such as:

Telenursing
Another document published
by the College of Registered
Nurses of Nova Scotia (the
College), entitled Telenursing
Practice Guidelines (2008),
provides additional information
on documentation related
to nursing services provided
via electronic means (e.g.,
telephone-based
client
consultations, telehealth).

Time efficient for detailed assessments

Standardization of assessments and care plans with the ability to customize as required
Large amounts of data can be stored in a small space
Information can be automatically transferred or populated to other areas of the chart
Increased security such as password protected access to client charts.
15

As in paper-based documentation systems, the reliability and trustworthiness of an electronic system is

essential and the principles of good documentation must be maintained. While the basic principles of
documentation used in paper-based systems would also apply in the case of electronic-based systems (e.g.,
computers, telephones, voice recording machines, videos) these new methods of recording, delivering and
receiving client data are posing new and constant challenges for agencies and nurses - both in terms of
confidentiality and security and in ensuring continuing education for healthcare providers.
Agencies must have clear policies and guidelines to address these challenges and other issues related to
technologies in documentation and registered nurses must advocate for agency policies/guidelines that reflect
and support quality, evidence-based practice. Agency policies related to electronic documentation should
clearly indicate how to:

correct documentation errors and/or make late entries

prevent the deletion of information
identify changes and updates in a health record
protect the confidentiality of client information
maintain the security of a system (e.g., regularly changing passwords, issuing access cards, virus
protection, encryption, well maintained firewalls)
track unauthorized access to client information
use a mixture of electronic and paper-based methods, as appropriate (policy should ensure continuity
of care is maintained)
back-up client information
document in the event of a system failure
obtain access to a specific group or area of information.

All entries made and/or stored electronically are considered a permanent part of a health record and may
not be deleted (e.g., e-mail and fax messages, including fax cover sheets; telehealth encounters). Client
information transmitted electronically must be stored (electronically or in hard copy) and, if relevant, may be
subject to disclosure in legal proceedings.

Faxing

Facsimile (fax) transmission of client information between healthcare providers is convenient and efficient. In
spite of this there is significant risk to the confidentiality and security of information transmitted via fax due to
the possibility of transmitting to unintended recipients. Agency policy should guide nurses in the acceptance
and transmission of faxes for the purposes of client care.
The confidentiality and security of transmitting client information via facsimile can be enhanced when nurses:
verify fax numbers and fax distribution lists stored in machine of sender prior to dialing
carefully check activity reports to confirm successful transmissions
note, on cover sheet, that the information being transmitted is confidential, and request verification
that a misdirected fax has been immediately destroyed without being read
make a reasonable effort to ensure that the fax will be retrieved immediately by the intended recipient
or will be stored in a secure area until collected
verify that information received is legible and complete (CRNBC, 2007).

Email

The use of electronic mail (e-mail) transmission by healthcare organizations and healthcare professionals is
becoming more widespread because of its speed, reliability, convenience and low cost. However, like faxes,
16

there is significant risk to the security and confidentiality of e-mail messaging. Messages can inadvertently be
read by an unintended recipient and while the message can be erased from the local computer, they are never
deleted from the central server and could be retrieved by unauthorized personnel. It is not recommended as a
method for transmitting clients health information.
In instances where an e-mail message is considered to be the preferred option to meet client needs, there
must be a reasonable belief that the transmission is secure (e.g., use of encryption software, user verification,
secure point-to-point connections). Agencies should also develop specific policies for transmitting client
information via e-mail to cover items such as the use of specific forms for e-mail purposes, the procedure to
obtain consent to use e-mail, and the use of initials, names, and hospital/ agency numbers.

When should RNs document?

Timely, Chronologically and Frequently
Contemporaneous documentation, defined as the completion of documentation as close as possible to the
time of care, enhances credibility and accuracy of health care records (CARNA, 2006). Documentation should
never be completed before it actually takes place.
Documenting events in the chronological order in which they took place is important, particularly in terms of
revealing changing patterns in a clients health status. Documenting chronologically also enhances the clarity
of communications enabling healthcare providers to understand what care was provided, based on what
assessment data, and then any outcomes or evaluations of that care (including client responses).
The frequency and amount of detail required in documentation is, generally, dictated by a number of factors,
including:

facility/agency policies and procedures

complexity of a clients health problems
degree to which a patients condition puts him/her at risk
degree of risk involved in a treatment or component of care.

While agency policies on documentation should be followed to maintain a reasonable and prudent standard of
documentation, nursing recording should be more comprehensive, in-depth and frequent if a patient is very ill,
very unpredictable or exposed to high risk (Canadian Nurses Protective Society, 2007, p.2).
The following table demonstrates how as clients change the frequency of documentation should also change:

Low

Medium

High

Acuity
Complexity
Variability
Frequency of
Documentation
(CRNBC, 2007)

17

Late, Delayed or Lost entries

As stated, documentation should occur as soon as possible after an event has occurred. When it is not possible
to document at the time of or immediately following an event, or if extensive time has elapsed a late entry is
required. Late entries should be defined by agency policy. Late entries or corrections incorporating omitted
information in a health record should be made, on a voluntary basis, only when a nurse can accurately recall
the event or care provided. Late entries must be clearly identified (e.g., Addendum to Care), and should be
individually dated. They should reference the actual time recorded as well as the time when the care/event
occurred and must be signed by the nurse involved.
A delayed entry may occur when two nurses enter data on the same patient. Delayed entries must be entered
on a chart on the same shift that the care was provided and/or the event occurred, even if the information is
not entered in chronological order. Delayed entries should be made according to agency policy.
In the event of a lost entry, the RN may be asked to re-construct the entry. Falsifying records is considered
professional misconduct according to the definition under Section 2(as)(ix) of the Registered Nurses Act (2006)
so the nurse must clearly indicate the information recorded as a replacement for a lost entry. Lost entries
should be made according to agency policy. If the care/event cannot be recalled, the new entry should state
that the information for the specific time of the event has been lost.

Conclusion
Quality documentation is an integral part of professional RN practice. It reflects the application of nursing
knowledge, skills and judgment, the clients perspective and interdisciplinary communications. These
guidelines will support RNs to contribute to the development of agency policy and promote evidenceinformed practice, which enables RNs to meet the Standards of Practice for Registered Nurses every day in
client care.

18

References
Association of Registered Nurses of Newfoundland and Labrador. (2010). Documentation standards for
registered nurses. St. Johns, NL: Author.
Canadian Nurses Association. (2008). Code of ethics for registered nurses. Ottawa, ON: Author.
Canadian Nurses Protective Society. (2009). Evidence. infoLAW, 18(2).
Canadian Nurses Protective Society. Charting: The legal aspects. Retrieved August 24, 2012, from: http://www.
cnps.ca/index.php?page=86.
Canadian Nurses Protective Society. (2009). Privacy and electronic medical records. infoLAW, 18(1).
Canadian Nurses Protective Society. (2007). Quality documentation: Your best defense. infoLAW, 1(1) .
College and Association of Registered Nurses of Alberta. (2006). Documentation guidelines for registered
nurses. Edmonton, AB: Author.
College of Nurses of Ontario. (2008). Practice standard documentation. Toronto, ON: Author.
College of Registered Nurses of British Columbia. (2007). Nursing documentation. Vancouver, BC: Author.
College of Registered Nurses of British Columbia. (2008). Practice standard for registered nurses and nurse
practitioners documentation. Vancouver, BC: Author.
College of Registered Nurses of British Columbia. (n.d.). Documentation in nursing practice workbook.
Vancouver, BC: Author.
College of Registered Nurses of Manitoba. (2005). Documentation system requirements standards of practice
application. Winnipeg, MB: Author.
College of Registered Nurses of Manitoba. (2005). Documentation standards of practice application. Winnipeg,
MB: Author.
College of Registered Nurses of Nova Scotia. (2005). Documentation guidelines for registered nurses. Halifax,
NS: Author.
College of Registered Nurses of Nova Scotia. (2000). Guidelines for telenursing practice. Halifax, NS: Author.
College of Registered Nurses of Nova Scotia. (2011). Medication guidelines for registered nurses. Halifax, NS:
Author.
College of Registered Nurses of Nova Scotia. (2011). Standards of practice for registered nurses. Halifax, NS:
Author.
Grant, A., & Ashman, A. (1997). A nurses practical guide to the law. In Canada Law Book Inc., (133-153).
Aurora, ON: Aurora Professional Press.

19

Harper, C. (2007). How interdisciplinary documentation improves the bottom line. Rehabilitation Nursing,
32(3), 91-92; 111.
Kirkley, D., & Renwick, D. (2003). Evaluating clinical information systems. JONA, (33)12, 643-651.
Lampe, S. (1997). Collaborative documentation: Key to success. The Journal of Nursing Administration, 27(10),
3.
Merriam-Webster Online. Retrieved August 24, 2012, from http://www.merriam-webster.com/
Nurses Association of New Brunswick. (2010). Practice standards: Documentation. Fredericton, NB: Author.
Potter, PA., Perry, AG. (2010). Canadian fundamentals of nursing. Toronto, ON: Elsevier Canada.
Registered Nurses Act, c. 21. (2006). In Statutes of Nova Scotia. Halifax, NS: Government of Nova Scotia.
Registered Nurses Regulations. (2009). Made under Section 8 of the Registered Nurses Act, c. 21, 2006. Halifax,
NS: Government of Nova Scotia.
Saskatchewan Registered Nurses Association. (2011). Documentation: Guidelines for registered nurses. Regina,
SK: Author.
Siddall, S., Barnes, D. (1999). Collaborative care documentation. Pediatric Nursing, 11(4), 30-32.

20

Glossary of Terms
Accountability: the obligation to acknowledge the professional, ethical, and legal aspects of ones role, and to
answer for the consequences and outcomes of ones actions. Accountability resides in a role and can never be
shared or delegated.
Adverse event: an unintended injury or complication, which results in disability, death or prolonged hospital
stay and is caused by healthcare management (Adverse Events in Canadian Hospitals Study Report, CIHI-CIHR,
2004).
Agency: facility or organization through which health services are provided or offered (e.g., district health
authorities, hospitals, community health centres, physicians offices, home care programs).
Authorized prescriber: a healthcare provider authorized by legislation to prescribe drugs and other health
products. In Nova Scotia, authorized prescribers include physicians, dentists, nurse practitioners, midwives,
optometrists, and pharmacists.
Client: the individual, group, community or population which is the recipient of nursing services and, where
the context requires, includes a substitute decision-maker for the recipient of nursing services (RN Act, 2006).
Collaborate: Building consensus and working together on common goals, processes, and outcomes. (CNA Code
of Ethics)
Competence: the ability to integrate and apply the knowledge, skills and judgment required to practice
safely and ethically in a designated role and practice setting and includes both entry-level and continuing
competencies (RN Act, 2006).
Competent: having or demonstrating the necessary knowledge, skills and judgments required to practice safely
and ethically in a designated role and setting. (CRNNS, 2009).
Competency: the integrated knowledge, skills, judgment and attributes required of a registered nurse to
practice safely and ethically in a designated role or setting. (Attributes include, but are not limited to, attitudes,
values, and beliefs.) (CNA Code of Ethics, 2008).
CRNNS: College of Registered Nurses of Nova Scotia; the regulatory/licensing body for registered nurses and
nurse practitioners in the province of Nova Scotia.
Documentation: refers to charts, charting, recording, nurses notes, progress notes. Documentation is written
or electronically generated information about a client that describes the care (observations, assessment,
planning, intervention and evaluation) or service provided to that client.
Electronic Health Record (EHR): health record of an individual that is accessible online from many separate,
interoperable automated systems within an electronic network (Health Canada). See Enterprise Medical
Record.
Electronic Patient Record: an electronic method of storing, manipulating and communicating medical
information of all kinds including text, images, sound, video and tactile senses, which are more flexible than
paper-based systems. Often referred to as a medical record, it contains a clients (patient) entire medical
history and information crucial to future care.
Electronic documentation: a document existing in an electronic form to be accessed by computer technology.
21

Electronic message system (e-mail): a system that transmits messages in electronic form over a
communications network of computers.
Encryption: a process of disguising data information as ciphertext, or data that will be unintelligible to an
unauthorized person.
Enterprise Medical Record (EMR): stores all clinical data entered on a client in the Nova Scotia Hospital
Information System (NShIS).
Intervention: task, procedure, treatment, function, drug or action with clearly defined limits.
Facsimile: a system of transmitting and reproducing graphic matter (as printing or still pictures) by means of
signals sent over telephone lines.
Firewall: a computer or computer software that prevents unauthorized access to private data (as on a
companys local area network or intranet) by outside computer users (as on the Internet).
Health record: a compilation of pertinent facts on a clients health history, including all past and present
medical conditions/illnesses/treatments, with emphasis on the specific events affecting the client during any
episode of care (e.g., hospital admission, series of home visits). All healthcare professionals providing care
create the pertinent facts documented in a clients health record. Health records may be paper documents
(i.e., hard copy) or electronic documents such as electronic medical records, faxes, e-mails, audio or
videotapes, or images.
Legal reviews: review of a health record when requested for legal purposes.
Policy: broad statement that enables informed decision-making, by prescribing limits and assigning
responsibilities/accountabilities. In terms of professional practice, policies are formal, non-negotiable,
clear, authoritative statements directing professional practice. Policies are realistic and achievable, based
on evidence or best practice, and should reflect the mission, vision, values and strategic directions of an
organization (Cryderman, 1999, p.16).
Password: a sequence of characters required for access to a computer system.
Patient Care System (PCS): within the Nova Scotia Hospital Information System (NShIS) this is where the list of
caregiver clients and caregiver intervention lists are accessed in order to document care. Documentation flows
to the Enterprise Medical Record (EMR).
Practice of nursing: the application of specialized and evidence-based knowledge of nursing theory, health and
human sciences, inclusive of principles of primary health care, in the provision of professional services to a
broad array of clients ranging from stable or predictable to unstable or unpredictable, and includes:
(i) assessing the client to establish the clients state of health and wellness,
(ii) identifying the nursing diagnosis based on the client assessment and analysis of all relevant data and
information,
(iii) developing and implementing the nursing component of the clients plan of care,
(iv) co-ordinating client care in collaboration with other health care disciplines,
(v) monitoring and adjusting the plan of care based on client responses,
(vi) evaluating the clients outcomes,
22

(vii) such other roles, functions and accountabilities within the scope of practice of the profession that
support client safety and quality care, in order to
(A) promote, maintain or restore health,
(B) prevent illness and disease,
(C) manage acute illness,
(D) manage chronic disease,
(E) provide palliative care,
(F) provide rehabilitative care,
(G) provide guidance and counseling, and
(H) make referrals to other health care providers and community resources,
and also includes research, education, consultation, management, administration, regulation, policy or system
development relevant to subclauses (i) to (vii)
(Registered Nurses Act, 2006)
Practice of nurse practitioners: means the application of advanced nursing knowledge, skills and judgment in
addition to the practice of nursing in which a nurse practitioner in collaborative practice may, in accordance
with standards for nurse practitioners, do one or more of the following:
(i) make a diagnosis identifying a disease, disorder or condition,
(ii) communicate the diagnosis to the client and health care professionals as appropriate,
(iii) perform procedures,
(iv) initiate, order or prescribe consultations, referrals and other acts,
(v) order and interpret screening and diagnostic tests, and recommend, prescribe or reorder drugs, blood,
blood products and related paraphernalia,
and also includes research, education, consultation, management, administration, regulation, policy or system
development relevant to subclauses (i) to (v).
(Registered Nurses Act, 2006).
Professional misconduct: includes such conduct or acts relevant to the practice of nursing that, having regard
to all the circumstances, would reasonably be regarded as disgraceful, dishonorable or unprofessional which,
without limiting the generality of the foregoing, may include:
(i) failing to maintain the College of Registered Nurses of Nova Scotia Standards for Nursing Practice,
(ii) failing to uphold the code of ethics adopted by the College,
(iii) abusing a person verbally, physically, emotionally or sexually,
(iv) misappropriating personal property, drugs or other property belonging to a client or a registrants
employer,
(v) inappropriately influencing a client to change a will,
(vi) wrongfully abandoning a client,
(vii) failing to exercise discretion in respect of the disclosure of confidential information,
(viii) falsifying records,
(ix) inappropriately using professional nursing status for personal gain,
(x) promoting for personal gain any drug, device, treatment, procedure, product or service that is
unnecessary, ineffective or unsafe
(xi) publishing, or causing to be published, any advertisement that is false, fraudulent, deceptive or
misleading,
23

(xii) engaging or assisting in fraud, misrepresentation, deception or concealment of a material fact when
applying for or securing registration or a licence to practise nursing or taking an examination provided for in
this Act, including using fraudulently procured credentials
(Registered Nurses Act, 2001).
Professional practice issue: any issue or situation that either compromises client care/service by placing a
client at risk, or affects a nurses ability to provide care/service consistent with the Standards of Practice for
Registered Nurses, Code of Ethics, other standards and guidelines, or agency policies or procedures (Resolving
Professional Practice Issues, CRNNS, 2012).
Progress notes: documentation of the progress of clients problems by all health team members. Nurses notes
are one component of the progress notes.
Responsibility: an activity, behaviour or intervention expected or required to be performed within a
professional role and/or position: may be shared, delegated or assigned. (Standards of Practice For Registered
Nurses, 2012.)
Self-regulation: the relative autonomy by which a profession is practised within the context of public
accountability to serve and protect the public interest. The rationale for self-regulation is the recognition that
the profession is best able to determine what can be practised, how it is to be practised, and who can practise,
as long as the public is well served.
Scope of practice: the roles, functions and accountabilities which members of a profession are legislated,
educated and authorized to perform.
Scope of employment: the range of responsibilities defined by an employer.
Telehealth: the delivery of health related services, enabled by the innovative use of technology, such as
videoconferencing, without the need for travel. Telehealth can refer to transmission of medical images for
diagnosis (referred to as store and forward telehealth) or groups or individuals exchanging health services or
education live via videoconference (real-time telehealth).
Telenursing: use of electronic means by registered nurses to establish communication links with clients and/or
other healthcare professionals in the delivery of professional nursing services.
Voicemail: an electronic communication system in which spoken messages are recorded or digitized for later
playback to an intended recipient.

24

Appendix A- Legislation affecting Nursing Documentation

Federal
Access to Information Act
http://laws-lois.justice.gc.ca/eng/acts/A-1/index.html
Controlled Drugs and Substances Act
http://laws-lois.justice.gc.ca/eng/acts/C-38.8/index.html
Personal Information Protection and Electronic Documents Act
http://laws-lois.justice.gc.ca/eng/acts/P-8.6/index.html
Privacy Act
http://laws-lois.justice.gc.ca/eng/acts/P-21/index.html
For information on where to obtain copies of current federal legislation, call the Government of Canada Inquiry
Centre at 1-800-O Canada or visit the Department of Justice website at http://laws.justice.gc.ca.

Provincial

Freedom of Information and Protection of Privacy Act

http://nslegislature.ca/legc/statutes/freedom.htm
Health Act
http://nslegislature.ca/legc/statutes/health.htm
Health Protection Act
http://nslegislature.ca/legc/statutes/healthpr.htm
Homes for Special Care Act
http://nslegislature.ca/legc/statutes/homespec.htm
Hospitals Act
http://nslegislature.ca/legc/statutes/hosptls.htm
Occupational Health and Safety Act
http://nslegislature.ca/legc/statutes/occph_s.htm
Personal Health Information Act
http://nslegislature.ca/legc/index.htm

Registered Nurses Act

http://nslegislature.ca/legc/statutes/regisnur.htm
For more information or to obtain copies of current provincial legislation, visit the Government of Nova Scotia
Publications website http://www.gov.ns.ca/snsmr/publications/ (go to Acts, Statutes and Regulations).

25

Appendix B- Practice Exercise

Questions - Workbook
Ms. Jones is a 24-year-old single mother just getting off the night shift. She reports to the Emergency
Department (ED) in the early morning with shortness of breath. She has cyanosis of the lips. She has had a
productive cough for 2 weeks. Her temperature is 38.2, blood pressure 110/76, heart rate 108, respirations
32, rapid and shallow and there is noted use of accessory muscles, O2 Saturation is 95% on room air. Breath
sounds are diminished in both bases, with coarse rhonchi in the upper lobes. You receive her for care from the
triage nurse.
How would you document your initial assessment?

The physician orders the following:

Arterial Blood Gases

CBC
Chest x-ray
Salbutamol 4 puffs and Ipratropium 4 puffs by MDI with spacer q 20 mins x 3

You start to carry out the orders and another ED nurse, Janice, offers her assistance. You review the chart and
orders with Janice and ask her to obtain the ABG sample while you administer the medications.
What would you document? What would you expect Janice to document?

The physician finishes the assessment and, based on the findings, Ms. Jones is diagnosed with pneumonia. You
and the physician go together to discuss this with Ms. Jones. When the physician communicates the diagnosis
and discusses the treatment plan with Ms. Jones she becomes upset. She states that she needs to have a
cigarette and to think about how she will afford the treatment medication. She states that she probably wont
fill the prescription for the antibiotic because she needs to buy cigarettes to help deal with her nerves and her
kids. She is angry and swears at both you and the physician.
How would you document this interaction with Ms. Jones?

26

You discuss some payment options with Ms. Jones to assist her pay for her medications and she agrees to try
some of these. The physician discharges her home.
How would you document this interaction with Ms. Jones?

Responses for Practice Exercise

The following responses are examples of how this situation could be documented using a narrative
documentation system.
Ms. Jones is a 24-year-old single mother just getting off the night shift. She reports to the Emergency
Department (ED) in the early morning with shortness of breath. She has cyanosis of the lips. She has had a
productive cough for 2 weeks. Her temperature is 38.2, blood pressure 110/76, heart rate 108, respirations
32, rapid and shallow and there is noted use of accessory muscles, O2 Saturation is 95% on room air. Breath
sounds are diminished in both bases, with coarse rhonchi in the upper lobes. You receive her for care from the
triage nurse.

Example 1
The physician orders the following:

Arterial Blood Gases

CBC
Chest x-ray
Salbutamol 4 puffs and Ipratropium 4 puffs by MDI with spacer q 20 mins x 3

You start to carry out the orders and another ED nurse, Janice, offers her assistance. You review the chart and
orders with Janice and ask her to obtain the ABG sample while you administer the medications.

Example 2

27

The physician finishes the assessment and, based on the findings, Ms. Jones is diagnosed with pneumonia. You
and the physician go together to discuss this with Ms. Jones. When the physician communicates the diagnosis
and discusses the treatment plan with Ms. Jones she becomes upset. She states that she needs to have a
cigarette and to think about how she will afford the treatment medication. She states that she probably wont
fill the prescription for the antibiotic because she needs to buy cigarettes to help deal with her nerves and her
kids. She is angry and swears at both you and the physician.

Example 3
You discuss some payment options with Ms. Jones to assist her to pay for her medications and she agrees to
try some of these. The physician discharges her home.

Example 4

28

29

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31