a documentation standard for the maternal and child health...

D o c u m e n t a t i o n s t a n d a r d f o r t h e m a t e r n a l a n d c h i l d h e a l t h n u r s e

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A documentation standard

for the maternal and child

health nurse in Victoria

Maternal and Child Health Nurse (MCH) Documentation Project Draft Final Report

Ms Catina Adams

2 January 2015


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Table of contents page

1. The maternal and child health nursing documentation project 1.1 Background 3

1.2 Governance 3

1.3 Legislative context and literature review 4

1.4 Consultation method 4

1.5 Consultant�s report 4

1.6 Information technology 5

1.7 Feedback from key stakeholders 5

2. Principles of documentation 2.1 Definition 7 2.2 Communication 8 2.3 Clinical safety 8 2.4 Legal requirements, including confidentiality and privacy 9 2.5 Ethical practice, including cultural safety 10 2.6 Professional standards, including accountability 11 2.7 Research and evidence base 11

3. Documentation standard for the maternal and child health

nurse in Victoria 12

Appendices

1. Contributors 15

2. Report of site visits � the nurses� voice 16

3. Questionnaire for site visits 18

4. Legislation 20

5. Professional standards and codes of practice 21

6. Australian nursing, midwifery and maternal and child health nurse

competencies 22

7. Documentation guide for maternal and child health nurses in Victoria 25

8. Templates for standard documentation 27

9. Documentation audit tool 28

10. MCH nurse abbreviations 30

Bibliography 35


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1. The maternal and child health nursing documentation project

1.1 Background

Nursing documentation is a necessary component of safe, ethical and effective nursing

practice. Nurses and midwives are required to make and keep records of their professional

practice in accordance with standards of practice, and organisational policies and

procedures.

According to the various nursing, midwifery and maternal and child health (MCH) nursing

standards and competencies that guide MCH nursing practice, each MCH nurse is expected

to complete documentation in a manner that is contemporaneous, comprehensive, logical,

legible, clear, concise and accurate. (National Competency Standards for the Midwife,

Australian College of Midwives [ACN] and the Nursing and Midwifery Board of Australia

[NMBA] 2006)

There is a wide variation in the documentation practices of MCH nurses in Victoria, and a

prescribed standard for MCH nurse documentation does not exist.

In 2014, the Victorian Association of Maternal and Child Health Nurses (VAMCHN) and the

Victorian Maternal and Child Health Coordinators Group (VMCHCG) identified the need to

develop a Victorian MCH nursing documentation standard.

1.2 Governance

In early 2014, the MCH Nursing Documentation Project Steering Committee was formed.

This Steering Committee initially comprised 3 representatives from VAMCHN and 3 from the

VMCHCG. A representative from the Australian Nursing Federation (Victorian Branch) was

later included.

The Steering Committee sought expressions of interest for a consultant to develop a MCH

documentation standard. In September 2014, Ms Catina Adams was engaged to undertake

the MCH nursing documentation project.

The project aimed to:

explore documentation practices within MCH nursing in Victoria;

identify examples of quality MCH documentation;

provide a list of accepted abbreviations to be used in MCH documentation; and

develop a standard for MCH nursing documentation in Victoria.


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1.3 Legislative context and literature review

In Stage 1 of the project, the consultant undertook a survey of the legislative requirements

for documentation and a review of the current literature on MCH nursing documentation.

This literature review revealed that there has been no research into MCH documentation in

the Victorian context. The literature review did identify some written standards of nursing

documentation, in New South Wales and in Canada, with elements potentially applicable to

MCH nurses in Victoria. Together with the relevant legislation and codes of practice, these

standards contributed to the creation of a draft Documentation standard for the maternal

and child nurse in Victoria.

1.4 Consultation method

Consultation with key stakeholders has been a critical component of the MCH nursing

documentation project. In Stage 2 of the project, the consultant undertook site visits at nine

Local Government Areas (LGAs). These occurred in a combination of rural, interface and

metropolitan areas (see Appendix 1). Over one hundred and fifty MCH nurses were

consulted during these visits. The purpose of the site visits was to identify examples of good

practice in MCH nursing documentation, and to ensure that the requirements of the

documentation standard could be accommodated within MCH nursing practice. A

questionnaire was used as a basis for the consultation (see Appendix 3).

The Consultant communicated with members of the Steering Committee via email during all

stages of the project, including a face-to-face meeting on 1st December 2014. The Steering

Committee has been actively involved in refining the draft standard, prior to distribution to

stakeholders. Further liaison will continue after the draft standard has been reviewed by key

stakeholders, to review feedback and finalise the standard.

On 4th December 2014, the Consultant presented to a general meeting of the Victorian

Association of Maternal and Child Health Nurses (VAMCHN). VAMCHN members were

invited to make written and verbal submissions during this meeting.

1.5 Consultant�s report

Stage 1 (literature review) and Stage 2 (consultation with practitioners) has enabled a

comprehensive examination of documentation practices, exploring gaps in documentation,

examining existing guidelines, current practices, templates, and other examples of

documentation tools. This examination has resulted in a report with recommendations

towards achieving a �best practice� MCH documentation standard; a list of standard

abbreviations used in MCH nursing; examples of frameworks or templates that may be

used; and a guide for MCH nursing documentation.


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1.6 Information Technology

The MCH Nursing Documentation Project has coincided with the ICT Project currently being

undertaken by the Municipal Association of Victoria (MAV) and the Department of

Education and Early Childhood Development (DEECD). It is intended that the final standard

will interface with existing technology systems and data collection systems, such as MaCHS

and Expedite, however, the MCH documentation standard has been written so that it can be

applied regardless of the documentation technology in use.

Nevertheless, the MCH documentation standard assumes the following parameters, which

will need to be supported by the forthcoming documentation technology:

1. If clinical observations can be collected and described in an automated way, then

they should be, for example, by using templates to record the physical assessment of

the child. Examples are attached under Appendix 8.

2. Documentation by exception should be supported through the effective use of

quality templates which adequately describe and reiterate the clinical norms, and

standards of care.

3. Double entry of information should be avoided, to ensure that reports, referrals,

alerts and plans are derived from one data entry source.

4. The free text field is an adjunct to the automated templates, to enable the recording

of subjective data collected from the client (where applicable), to highlight and

describe care plans, to record significant variances, and record information from

other care providers. It should also be used to note progress made with issues noted

previously.

With the use of current technology and future planned systems, all free text entries are date

stamped, with an author ascribed via password. It should be noted that the KAS template

screens in MaCHS have no such security, and can be annotated without an author or date

stamp ascribed. This should be addressed in future iterations of the technology.

Nurses should only access a health record on a �needs-to-know� basis. Current IT systems

do not have a browse history, but this should be a feature of future tender requirements.


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1.7 Feedback from stakeholders

Stage 4 of the project involves consultation with key stakeholders regarding the MCH

nursing documentation final report. This is a critical phase of the MCH nursing

documentation project, and will include dissemination of the draft documentation standard

and report.

Key stakeholders are invited to make written submissions regarding the documentation

standard. Key stakeholders include:

Victorian MCH nurses

VAMCHN members

MCH nurse coordinators

Australian Nursing and Midwifery Federation (Vic Branch)

MCH nurse academics from Latrobe and RMIT Universities

DEECD

MAV

Submissions will be reviewed by the MCH nursing documentation project consultant prior to

developing the MCH nursing documentation final report.

Submission can be made online at [email protected] by 26th January 2015.


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2. Principles of documentation

2.1 Definition

Documentation is anything written or electronically generated that describes the status of a

client or the care or services given to that client (Potter PA, Perry AG 2010). In the MCH

nursing context, this may include:

written and electronic health records, including MCH notes in the free text field, and in the �Green Book� or Child Health Record;

audio and video tapes; emails and facsimiles; images (photographs and diagrams); observation charts; automated documentation systems including MaCHS and Xpedite.

According to Potter and Perry (2010), good documentation has six important characteristics. It

should be:

factual, accurate, complete, current (timely), organised, and compliant with standards.

Documentation allows nurses and other care providers to communicate about the care

provided, and enables care providers to use current, consistent data and care goals to

facilitate continuity of care. Documentation also promotes good nursing care and supports

nurses to demonstrate that they meet professional and legal standards.

Quality (MCH) nursing documentation is expected to:

Provide evidence of care and the client�s response to that care; Be an important source of reference between nurses, midwives, and other members

of the health team; Facilitate the continuity of quality care by keeping all members of the team informed

of the family�s current health status; Improve outcomes for families; and Protect nurses if they are called upon to explain the care they have given to a family.

(Sydney South West Area Health Service (SSWAHS), 2009)


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2.2 Communication

Documentation is one/ a critical means by which nurses communicate their nursing

assessment and observations, the plan of care, health promotion information that is

conveyed, interventions that are carried out, and the outcome of those interventions.

Nurses communicate via written documentation to enable continuity of care and as an aide

to memory, so that appropriate follow-up from the previous appointment can occur.

The consequences of inaccurate or incomplete documentation are that care is fragmented,

and (interventions or referrals) could be delayed or omitted (Potter and Perry, 2010). When

nurses document the care they provide, other members of the team are able to review the

documentation and plan their own contributions to effective engagement. Continuity of

care is achieved through effective and accurate handover between nurses (NSW Health,

2014).

A good test to evaluate whether a nurse�s documentation is satisfactory is to ask the

following question � �If another nurse took over the care of this family, does the record

provide sufficient information for the seamless delivery of safe, competent and ethical care�

(College and Association of Registered Nurses of Alberta (CARNA), 2006).

2.3 Clinical safety

The MCH nurse undertakes a physical assessment of the child at each appointment, a

psycho-social assessment of the parents and child, undertakes health promotion and

anticipatory guidance, and works with the family in partnership to support the parent�s

goals in raising their child (VAMCHN, 2010).

The documentation from the consultation must record the breadth and substance of the

communication that has occurred, as well as documenting the clinical observations that

have been made. Documentation must be factual and to the point, enabling an independent

clinician to fully understand the previous consultation (NSW Health, 2014).

Most methods of documentation fall into one of two categories: Documentation by

inclusion, or documentation by exception. Documentation by exception only notes those

observations which are a variance to the norm. Documentation by exception is only

appropriate where standards of clinical assessment are explicitly described and universally

applied (College of Registered Nurses of British Columbia (CRNBC, 2013).

The use of abbreviations, symbols and acronyms can be an efficient form of documentation

if their meaning is well understood by everyone. Abbreviations that are obscure, obsolete,


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idiosyncratic or have multiple meanings can lead to errors, can cause confusion and waste

time (College of Registered Nurses of Nova Scotia (CRNNS), 2012)

Any abbreviations must be approved and consistently applied. For example, �PE� in a

midwifery context would mean Pre-eclampsia, but in a nursing context, �PE� is an

abbreviation for Pulmonary Embolus. If there is any doubt, then the MCH nurse must write

all words in full.

Documentation may comprise objective and subjective data, but it should be clear from the

writing, which statements are objective and which are subjective. Objective statements are

those expressing or dealing with facts or conditions as perceived, without distortion by

personal feelings, prejudice or interpretations (CRNNS, 2012). Objective data is observed or

measured. Subjective data may include statements or feedback from a client, and can be

expressed using quotation marks, i.e. mother states �I�m feeling low today�.

Nurses should document what they see, not what they think, and should avoid making

conclusive statements prefaced by words such as �appears� and �seems�. The use of words

such as �seems, �appears� and �apparently� suggest that the nurse does not know the facts

and demonstrates uncertainty (CRNNS, 2012).

During the site visits, nurses described the difficulty they felt in documenting observations

that they felt they couldn�t describe objectively, i.e. when their �spider senses� were

tingling. When challenged, however, the nurses were usually able to describe objectively

what it was that has made them uneasy. And this is important, because if these �more

difficult to describe� observations are not documented, then the full clinical picture for the

family is lost.

Nurses should ensure that they document at the time of the consultation, or as soon as

possible afterwards, as delays can cloud the memory of events and increase the possibility

of errors. This is particularly the case for MCH nurses, who see a number of clients in a day,

one after the other (CRNBC, 2008).

2.4 Legal requirements, including confidentiality and privacy

Documentation may be subpoenaed as evidence in legal proceedings or professional

tribunals, thus subjecting it to the highest level of scrutiny.

Documentation is a permanent record and should provide a comprehensive account of care

provided to a family. Documentation also demonstrates whether or not a MCH nurse has

applied nursing knowledge, skills and judgement according to nursing and midwifery

standards (NMBA, 2006).


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Nurses must safeguard the privacy, security and confidentiality of health records. Failing to

keep records as required, falsifying a record, signing or issuing a document that the nurse

knows to include a false or misleading statement, or giving information about a client

without consent may be found to constitute unprofessional conduct by the Australian

Health Practitioners Regulation Agency (AHPRA) and the Nursing and Midwifery Board of

Australia (NMBA).

Technology does not change the client�s right to privacy of health information.

Confidentiality of all information in a health record is essential, and relates to access,

storage, retrieval and transmission of a client�s information. (CRNNS, 2012)

Documentation should be maintained in areas where the information cannot be easily read

by casual observers. This care should also apply to keeping passwords relating to access to

electronic systems of health information safe to limit unauthorised access.

If a written record is ever used, then it must begin with a date and time, and end with the

author�s signature and designation. There should be no empty lines.

2.5 Ethical practice, including cultural safety

�The nursing profession ... acknowledges the diversity of people constituting Australian

society� and the responsibility of nurses to provide just, compassionate, culturally

competent and culturally responsive care to every person requiring or receiving nursing

care.� (NMBA, 2008).

MCH nurses are accountable to both the Nurses� and Midwives� Codes of Ethics (NMBA,

2008). Encompassed within these codes is the requirement that the nurse has an ethical

responsibility to respect a client�s informed choice which includes choices related to lifestyle

we may not personally agree with, including risk taking behaviours. The nurse must

document the objective data and should be cautious not to place a value judgement on the

behaviours. At all times, the MCH nurse must avoid labelling clients or drawing subjective

conclusions.

If the risk taking behaviour entails risk to a child, then the MCH nurse is mandated to adhere

to legislative requirements, and document and report appropriately.

If a nurse makes value judgements or unfounded conclusions, these comments might imply

a dislike for the client, which could be interpreted to mean that the care and support

provided was sub-standard, or that observations were not objective and accurate. So

instead of noting, �the client is pushy and aggressive� it would be correct to document what

has been observed, for example, �the client has been shouting and swearing�.


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2.6 Professional standards, including accountability

Nurses are responsible and accountable for documenting the care and advice they

personally provide to the client. Using Information Technology (IT) systems, nurses must

ensure that their password is secure and that any notes under their login have been written

by them. Electronic systems have inbuilt safeguards to ensure that date stamps are

recorded, the author is identified, and the deletion of a record is not possible. Any written

notes, however, must be signed and dated by the author.

Audits of clinical documentation can be used to evaluate quality of services and

appropriateness of care. This enables quality improvement initiatives and risk management

assessment for the benefit of clients, staff and organisations. This task is made easier if

documentation is standardised.

2.7 Research and evidence base

Documentation provides valuable data for clinical research and workload management,

both of which have the potential to improve client outcomes. It can be used to quantify the

care that a client has received, the effectiveness of any interventions, and also offers the

nurse the opportunity for reflective practice, by reviewing and examining his or her own

notes. Review of documentation informs and enables reflective practice.

Documentation must accurately reflect the care that has been provided. It is a simple

matter to record the objective measures of the physical assessment, however the emotional

and educational support that is given to families is more difficult to document objectively,

and is therefore often not described in the notes. This means that often the majority of the

work of MCH nurses is not effectively described, and is therefore lost to future researchers.


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3. Documentation standard for the maternal and child health nurse

in Victoria

The maternal and child health (MCH) nurse is expected to complete documentation in a

manner that is contemporaneous, comprehensive, logical, legible, clear, concise and

accurate (NMBA, 2006).

1. Legal requirements, including privacy and confidentiality

The MCH nurse safeguards client health information and acts in accordance with the nursing

and midwifery Standards, and the applicable legislation.

The MCH nurse meets the standard by:

adhering to legal requirements in all aspects of documentation;

ensuring that relevant client care information is captured in a permanent record;

maintaining confidentiality of client health information, including passwords or

information required to access the client health record;

keeping in mind that the child or either parent can access the notes in the future

under Freedom of Information;

understanding and adhering to policies, standards and legislation related to

confidentiality;

accessing only information for which the nurse has a professional need to provide

care;

obtaining and recording informed consent from the client to use and disclose

information to others;

using a secure method such as a secure line for fax or e-mail to transmit client health

information (for example, making sure the fax machine is not available to the public);

retaining health records for the period the organization�s policy and legislation

stipulates; and

ensuring the secure and confidential destruction of temporary documents that are no

longer in use.


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2. Professional practice

The MCH nurse is accountable for ensuring his/her documentation is accurate, timely and

complete.

A MCH nurse meets this standard by:

documenting in a timely manner and completing documentation during, or as soon as

possible after, the consultation;

documenting the location, date and time that the consultation occurred;

documenting who was present at the consultation;

indicating when an entry is late as defined by organisational policies;

if using an electronic data system, ensuring that the nurse�s password is secure, and

that any entries made using a nurse�s login are her own documentation; an exception

is where students use a nurse�s log in. In this case the name of the student needs to be

recorded; and

if using a paper system, ensuring that the entries are chronological, without empty

lines, dated, name printed and signed by the author, with full details as above; never

deleting, altering or modifying anyone else�s documentation; and ensuring that

documentation is completed by the individual who performed the action or observed

the event.

3. Communication and coordination of care

The MCH nurse ensures that his/her documentation presents an accurate, clear and

comprehensive picture of the family, the nurse�s interventions and plans, and the client�s

outcomes.

A MCH nurse meets this standard by:

ensuring that documentation is a complete record of the consultation and reflects all

aspects of the nursing process, including assessment, planning, intervention and

evaluation;

documenting both objective (from nurse) and subjective (from client) data.

Documentation should reflect a nurse�s observations and should not include

unfounded conclusions, value judgments or labelling. Subjective data can be recorded

using the client�s words;

ensuring that the plan of care is clear, current, relevant and individualized to meet the

client�s needs and wishes;


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collecting data as listed in the MCH service practice guidelines for the relevant Key and

Stage (KAS) consultation;

ensuring that referrals and alerts are recorded in the history;

minimizing duplication of information in the health record;

using abbreviations and symbols appropriately by ensuring that each has a distinct

interpretation and appears in a list with full explanations approved by the organization

or practice setting; and

with hand-written documentation, providing a full signature or initials, and

professional designation; ensuring that hand-written documentation is legible and

completed in permanent ink.

4. Critical thinking and analysis

The MCH nurse ensures that his/her practice reflects evidence of self-appraisal and

reflection on practice, and the value of evidence and research for practice.

The MCH nurse meets this standard by:

practising within an evidence-based framework;

demonstrates awareness of current research in own field of practice;

uses relevant literature and research findings to improve current practice

maintains accurate documentation of information which could be used in nursing

research;

recognises that quality improvement involves ongoing consideration, use and review

of practice in relation to practice outcomes, standards and guidelines and new

developments;

participates in case review activities, and clinical audits; and

undertakes regular self-evaluation of own nursing practice.


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Appendix 1. Contributors

Over one hundred and fifty maternal and child health nurses from the following Local

Government Areas:

City of Ballarat

City of Casey

City of Greater Geelong

City of Melbourne

City of Stonnington

City of Wodonga

Maribyrnong City Council

Melton City Council

Surf Coast Shire

Wyndham City Council

Victorian Maternal and Child Health Coordinators Group (VMCHCG)

Victorian Association of MCH Nurses (VAMCHN)

MCH documentation Steering Committee Members/Representatives

The project has the financial support of the VMCHCG and VAMCHN. The MCH

Documentation Steering Committee is representative of the two key stakeholders in the

project.

Victorian MCH Co-ordinators Group Victorian Association of MCH Nurses

Helen Watson (Kingston City Council) Rayleen Breach (Hume City Council)

Nicole Carver (City of Melton) Deidre Stuart (Glen Eira Council

Bernie Cavanagh (City of Ballarat) Emma Meredith (City of Darebin)

Australian Nursing and Midwifery Federation (Victorian Branch)

Belinda Clark (Professional Officer)


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Appendix 2. Report of the site visits � the nurses� voice

The majority of the site visits were undertaken in November 2014, with ten Local Government Areas (LGAs) volunteering to participate. Some of the LGAs provided written information; one of the meetings was by teleconference, and the rest were face-to-face meetings, generally including all members of the MCH nursing team. A small number of site visits were with the MCH leadership team only.

Prior to the meeting, each LGA was asked to provide some background information and to describe current practice around documentation. This was done via a questionnaire (appendix 3).

The discussions at the site visits were lively and broad-ranging - passionate, sometimes cynical, contradictory, or in furious agreement. The responses to questions were emphatic, intelligent, and thoughtful. The group of over one hundred and fifty nurses generously contributed their time and ideas to support the creation of a MCH documentation standard.

During the discussions, some interesting insights emerged about the work of MCH nurses, particularly around when, where, how and what they document.

There was a wide variation in when nurses document their notes. About half of the nurses said that they tried to finish their notes within the time allocated for the appointment, before the next client came in. A half hour appointment therefore represented 20-25 minutes of face-to-face client time, with five to ten minutes of notes.

Other nurses said that the half hour appointment was entirely spent with the client, that they would jot down some points or keywords during the consultation, and would write up the notes later in �admin� time.

Many nurses cited a lack of time being a barrier to good documentation, arguing that if they had more time they would write better notes. Nurses described feeling under pressure to write extensive and detailed notes, and felt that these expectations had increased. Some very experienced nurses noted that because there is now longer intervals between consultations, so much more needed to be covered in each appointment adding to the documentation load.

Other nurses questioned whether more time would improve the quality of the consultation, or the quality of the notes. Some nurses argued strongly that writing �War and Peace� was poor documentation practice, a waste of time, obscuring the important detail of the consultation.

Another interesting discussion ranged around where documentation occurred � referrals, reports, the electronic notes and the use of the �Green Book� or the Child Health Record. When asked what they wrote in the book, the MCH nurses� responses ranged from:


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1. Very little. I write up the physical measurements in the front pink summary page, I sometimes graph the weights or I will show the parents how to do it. If the PEDS hasn�t been completed I will fill it out with the client.

2. I write a little bit under each heading on the KAS page. I write it in �non-nurse� language for the parents to enjoy the comments. Some nurses sign and date these notes, others leave them unsigned.

3. I use the notes page to write out plans for the client, i.e. feeding or sleeping plans. I will also use the notes page to make referrals to the GP, or to provide simple instructions i.e. thrush treatment.

4. Almost all nurses said that very few parents write anything in the book, despite encouragement from the nurse.

In describing how they write their notes, nurses spoke about �templates�, although the term �template� came to mean something different to each team.

1. Some nurses use a template as a word-processing short cut, with standard free-text descriptions for each Key Age and Stage consultation, which can be cut and pasted and then personalised to suit the consultation underway. Some nurses love this tool, they feel it reduces their typing time, and ensures that key points are documented. Other nurses were strident in their opposition. They felt it was lazy, unprofessional, depersonalised the client, and they felt that their personal voice was lost in using the generic prose.

2. Some teams use a template which provides a scaffold for the documentation. It comprises only headings, which enables a sequence and structure to the free text field. One team described the process of implementation, firstly requiring all nurses to use the template �unless they could demonstrate that their notes were better without it�. After some initial resistance it has been universally adopted.

3. A third use of the term template describes the KAS screens, with drop down menus, and set fields, thereby automating a part of the documentation, particularly around physical assessment and measurement.

Some nurses expressed wariness around the creation of a documentation standard. These nurses argued strongly that to have �standardised documentation� diminished their professional expertise, and diluted the individual voice of the nurse. These nurses said they would resist being required to conform to a prescribed structure to the notes.

Other nurses argued that having a standard for MCH documentation, did not necessarily equate to standardised documentation.

All nurses agreed that more education to develop good documentation skills was required, and also a Documentation Guide specifically for MCH nurses would help to improve the quality of the nursing notes.


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Appendix 3. Questionnaire for the site visit

The MCH nursing documentation project

Some background information

Number of nurses employed � EFT

Number of birth enrolments � 2013-2014

Metropolitan, Rural or interface LGA?

What IT system do you use for documentation?

Do you maintain a paper record as well?

Do you have an Enhanced service? How many nurses? Parent support workers? Social

workers?

Have your notes ever been subpoenaed?

Work already done

Have you undertaken a review of MCH nursing documentation in your LGA?

Is there a report?

Have you created any standards for documentation?

How have these been described?

How do you monitor these standards?

Do you have an audit tool?

Do you use any form of template for documentation?

Do you have a Style or Documentation Guide?


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Current practice

Can you provide some examples (client and nurse de-identified) of what you consider to be

a well-documented consultation?

What elements do you consider to be important in good documentation?

Can you give some examples of poor documentation? Client and nurse, de-identified.

Questions

In a 30 minute consultation, how much time would you expect a nurse to spend on writing

notes?

Do you feel that you have received adequate/appropriate education on nursing

documentation?

What are the barriers to good documentation?

What assists good documentation?

Would a professional standard be helpful to you? As a nurse? As a Team

Leader/Coordinator?

Do your clients know what you are writing? Should they?

How do you document correspondence received about a client � i.e. Paediatrician reports,

Social Work referrals, audiology reports?


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Appendix 4. Legislation

Equal Opportunity Act 2010

Health Practitioner Regulation National Law (Victoria) Act 2009

Family Violence Protection Act 2008

Public Health and Wellbeing Act 2008

Charter of Human Rights and Responsibilities 2006

Children, Youth and Families Act 2005

Child Wellbeing and Safety Act 2005

Occupational Health and Safety Act 2004

Racial and Religious Tolerance Act 2001

Health Records Act 2001

Information Privacy Act 2000

Freedom of Information Act 1982


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Appendix 5. Professional standards and codes of practice

The Nursing and Midwifery Board of Australia (the National Board) undertakes functions as set by the Health Practitioner Regulation National Law, as in force in each state and territory (the National Law).

The National Board regulates the practice of nursing and midwifery in Australia, and one of its key roles is to protect the public. The National Board does this by making sure that only nurses and/or midwives who are suitably qualified to practise in a competent and ethical manner are registered.

The Nursing and Midwifery Board of Australia approves codes and guidelines and position

statements to provide guidance to the professions, to clarify expectations on a range of

issues.

Some of these include:

Nursing and Midwifery Board of Australia

- National competency standards for the midwife (2006)

- National competency standards for the nurse (2006)

- Code of professional conduct for midwives (2008)

- Code of ethics for midwives (2008)

- Code of professional conduct for nurses (2008)

- Code of ethics for nurses (2008)

- Professional boundaries for midwives (2010)

- Professional boundaries for nurses (2010)

All available at: http://www.nursingmidwiferyboard.gov.au.

- VAMCHN Competency Standards for the Maternal and Child Health Nurse in Victoria

(2010)

Available via the VAMCHN website: http://www.vamchn.org.au/


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Appendix 6. Australian nursing, midwifery and MCH nursing

competencies

The following competencies have been collated from the standards applicable to the MCH

nurse in Victoria which relate specifically to documentation.

National competency standards for the registered nurse (NMBA, 2006)

The competencies which make up the National Board competency standards for the registered nurse are organised into domains: Professional practice; Critical thinking and analysis; Provision and coordination of care; and Collaborative and therapeutic practice.

Professional practice

1.1 Complies with relevant legislation and common law:

describes nursing practice within the requirements of common law

Critical thinking and analysis

3.3 Demonstrates analytical skills in accessing and evaluating health information and research evidence:

maintains accurate documentation of information which could be used in nursing research

Provision and coordination of care

6.3 Documents a plan of care to achieve expected outcomes:

ensures that plans of care are based on an ongoing analysis of assessment data plans care that is consistent with current nursing knowledge and research, and documents plans of care clearly

Collaborative and therapeutic practice

10.2 Communicates nursing assessments and decisions to the interdisciplinary health care team and other relevant service providers:

maintains confidentiality in discussions about an individual/group�s needs and progress

demonstrates skills in written, verbal and electronic communication, and documents, as soon possible, forms of communication, nursing interventions

and individual/group responses


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National competency standards for the midwife (ACM NMBA, 2006)

The four domains in the provision of woman�centred midwifery care include legal and professional practice, midwifery knowledge and practice, midwifery as primary health care and ethical and reflective practice.

Legal and professional practice

Element 1.1 Demonstrates and acts upon knowledge of legislation and common law pertinent to midwifery practice.

Cues � Identifies and interprets laws in relation to midwifery practice, including the administration of drugs, negligence, consent, report writing, confidentiality, and vicarious liability.

Element 1.3 Formulates documentation according to legal and professional guidelines.

Cues � Adheres to legal requirements in all aspects of documentation

� Documentation is contemporaneous, comprehensive, logical, legible, clear, concise and accurate, and

� Documentation identifies the author and designation.

Midwifery knowledge and practice

Element 3.3 Plans and evaluates care in partnership with the woman.

Cues � Listens to the woman to identify her needs. Involves the woman in decision making

� Obtains informed consent for midwifery interventions, and

� Documents decisions, actions and outcomes including the woman�s response to care.

Midwifery as primary health care

Element 8.1 Demonstrates effective communication with midwives, health care providers and other professionals.

Cues � Uses a range of communication methods including written and oral

� Demonstrates effective communication during consultation, referral and handover.


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Competency Standards for the Maternal and Child health Nurse in Victoria (VAMCHN, 2010)

The standards are divided into four domains: legal, professional and ethical practice; promotion of child and family health and wellbeing through knowledge and practice; promotion of maternal and child health within the context of public health policy; and knowledge development and research.

Competency 1: Comply with the legislation and common law applicable to maternal and child health nursing practice

Element 1.3 Document according to legal and professional guidelines.

Validation � Adheres to legal requirements in all aspects of documentation

� Documents in a �comprehensive, contemporaneous, legible, clear, concise and accurate manner� (ANMC 2006).

Competency 10: Undertake all interactions using and promoting effective communication skills

Element 10.1 Undertake all consultations utilising the nursing process of assessment, plan, implementation and evaluation.

Validation � Records clear and concise documentation


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Appendix 7. A documentation guide for MCH nurses

Your documentation is a necessary component of safe, ethical and effective nursing

practice. According to the nursing, midwifery and MCH nursing standards and

competencies, you are expected to complete documentation in a manner that is

contemporaneous, comprehensive, logical, legible, clear, concise and accurate (NMBA,

2006).

Documentation is anything written or electronically generated that describes the status of a

client or the care or services given to that client (Potter PA, Perry AG 2010) and it should be

factual, accurate, complete, current (timely), organised, and compliant with standards.

Good documentation allows you to communicate with other care providers about the care

provided, and promotes good nursing care, supporting you to meet professional and legal

standards. Your notes reflect the level of care you have given to your client. If you have to

give evidence in court at a later date, you will rely on your notes to remember the details of

the care you provided to the individual client.

Quality nursing documentation is expected to:

Provide evidence of care and the client�s response to that care;

Be an important source of reference between nurses, midwives, and other members

of the health team;

Facilitate the continuity of quality care by keeping all members of the team informed

of the family�s current health status;

Improve outcomes for families; and

Protect nurses if they are called upon to explain the care they have given to a family.

(Sydney South West Area Health Service (SSWAHS), 2009)

This guide is intended to assist you with your documentation

What should be recorded in the automated templates? Eg MaCHs

and Expedite

1. Documentation by exception can be supported through the effective use of

templates which describe and reiterate the clinical norms, and standards of care. For

example, if hips are checked at every consultation, then it can be ticked off as done

on the template. If there is a variation to the clinical norm, or it is not done, it can be

described either in the free text field, or if the template supports a phrase or two of

additional text, it can be recorded there.


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2. If there is a variation to the clinical norm, the MCH must document the action she

has taken, whether that be a referral or a recommendation to the parent. By

documenting the action taken, it can be followed up at the next consultation.

3. Clinical observations should be collected and described by using templates to record

the assessment of the child or parent, such as physical measurements, input and

output, EPDS scores.

4. All questions for which there can be a Yes or No, or Pass or Fail answer should be

included in the template. For example, was the hearing test done and what was the

result; was the Newborn Screening Test done; questions about smoking; was the KAS

info pack given and discussed;

5. Demographic data should be collected via a drop down box in the template, for

example, Aboriginal or Torres Strait Islander status, country of birth, employment,

Health Care Card status, etc.

6. Double entry of information should be avoided, to ensure that reports, referrals,

alerts and plans are derived from one data entry source, to improve accuracy and

efficiency.

What should be recorded in the free text field?

The free text field should be used to record subjective data (where applicable), to highlight

and describe care plans, and the progress of previously identified issues, to record

significant variances, and information from other care providers. It should include:

When and where you had contact with the client;

Who was present;

Your observations of the client that are not captured elsewhere (objective data),

including observations of family interaction;

Any relevant information provided directly by the client which you can quote directly

(subjective data);

Interventions and/or plans;


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Appendix 8. Templates for standard documentation

(to be completed to conform with the MCH ICT project)


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Appendix 9. Documentation audit tool

Nurse: Date: Type of KAS: Auditor:

Item Present Absent N/A Comment

Name and address are correctly spelt. Email

and mobile phone numbers up to date.

Enrolment and birth notice received date

entered. If no birth notice, then reason

given � i.e. born outside Victoria

ATSI status noted

Country of birth and interpreter required?

Year of arrival in Australia?

Health care card and/or Medicare number

recorded

Privacy Act discussed and ticked

Demographic data � housing, occupation of

both parents

Birth and pregnancy screens completed,

family medical history.

Breastfeeding status noted

Parents and other children correctly linked

(ensure the mother is not already in the

database).

Physical assessment completed and

recorded as listed in MCH service practice

guidelines for relevant KAS visit.

Provision of health promotion info recorded

as given. Or declined.

Appropriate alerts recorded and reviewed

for currency.

If no longer at risk, teddy bear or red alert

has been removed/closed off.

Counselling and referral screens used if

applicable


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Item Present Absent N/A Comment

Documentation should be completed on the

day of the consultation. If there is a delay,

the notes should commence with

�retrospective notes for KAS visit on �,

delayed because of �.�

Identify who is present at the consultation

Time and date recorded, if not

automatically time and date-stamped.

Must include all of the work of the MCH

nurses - including education and

psychosocial support.

The free text notes should be presented in a

logical and sequential manner (Can use a

template for headings)

Only uses standard abbreviations

Observation of interaction between family

members, parents and children

Information about any major changes i.e.

moving house

Any exceptions to usual care and

assessment. Document reason for variance,

advice given, follow up action to be taken by

nurse

Telephone calls and emails transcribed into

the free text field

Notes made regarding progress of any

problems noted at previous visit

No unnecessary information i.e. �KAS pack

given and discussed�. A note should be

made if parent declines to take information

Immunisations only if a reaction noted or

immunisations overdue (exception DHS

clients who need this information for CPU)

Sensitive information about parents is only

in the respective primary carer or spouse

notes

Contact details of any CPU staff or other

practitioners involved are noted


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Appendix 10. MCH nurse abbreviations

The following abbreviations have been standardised to ensure consistent and effective communication. This

list has been created from lists provided by the nurse teams contributing to the project.

A Abs antibiotics

Ac before food

A/F artificially fed

A/N antenatal

ant font anterior fontanelle

APH ante-partum haemorrhage

approp appropriate

approx approximate

appt appointment

ARM artificial rupture of membranes

ASAP as soon as possible

ASD atrial septal defect

ATSI Aboriginal and Torres Strait Islander

Ax Assessment

B BA bowel action

Ba baby

BBA born before arrival

Bd twice daily

B/F breastfed

BP blood pressure

B/W birth weight

C CALD culturally & linguistically diverse

CHD congenital heart disease

Chn children

Cms centimetres

CMV cytomegalovirus

CP cerebral palsy

CPD cephalo-pelvic disproportion


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D D&C dilation & curette

DDH developmental dysplasia of hip

DNA did not attend

DOB date of birth

DVT deep vein thrombosis

DW discharge weight

E EBM expressed breast milk

EDD expected date of delivery

EHVS enhanced home visiting service

EMCH Enhanced maternal and child health

EPDS Edinburgh postnatal depression scale

Enc encouraged

Epis episiotomy

Eval evaluation

F F/U follow up

Fa father

FBE Full blood examination

FCM full cream milk

FD forceps delivery

FDIU Foetal death in utero

FV Family violence

G G1 P0 Gravida (no.) Para (no.)

GA general anaesthetic

Gest gestation

GOR gastro oesophageal reflux

GP general practitioner

GTT Glucose tolerance test

H HC head circumference

H/V home visit

Hb haemoglobin

Hep B hepatitis B


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Hib haemophilus influenza b

HITH Hospital in the Home

HIV human immunodeficiency virus

HT hypertension

I Imm immunisation

IUD intra-uterine device

IUGR intra-uterine growth retardation

IVP intravenous pyelogram

K KAS key age & stage

L L left

LBW low birth weight

LUSCS lower uterine segment caesarean section

M MGF maternal grandfather

MGM maternal grandmother

Misc miscarriage

MIST Melbourne initial screening test

MMR measles mumps rubella vaccine

Mo mother

MRSA Methicillin-resistant Staphylococcus aureus

Mx Management

N NAD no abnormalities detected

NB nota bene - note well

NESB non-English speaking background (now CALD)

NICU Neonatal Intensive Care Unit

nocte night

NVD/NVB normal vaginal delivery/birth

O O/E on examination

O2 oxygen

O/P outpatient

P P plan, planning

paed paediatrics, paediatrician


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Pc after food

PE pre-eclampsia

PEDS parents evaluation of development status

PGF paternal grandfather

PGM paternal grandmother

PKU phenylketonuria

post font Posterior fontanelle

PPH postpartum haemorrhage

PRN as required

PV per vagina

Q QID four times a day

R R right

Ref refer

Refd referred

resps respirations

R/V review

Rh rhesus

Rh NEG rhesus negative

Rh POS rhesus positive

Rpt repeat

Rx Treatment

S S&S signs and symptoms

S/B seen by

satis satisfactory

SBR serum bilirubin

SCN Special Care Nursery

SFD small for dates

Sib sib(s) sibling(s)

SIDS Sudden infant death syndrome

Sl slight

SpPth speech pathologist


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STI sexually transmitted infection

SUDI sudden unexpected death of infant

Sx Symptoms

T Tds three times day

TOP termination of pregnancy

TPR temperature pulse respirations

Tx Transfer

U umbi umbilicus

URTI upper respiratory tract infection

UTI urinary tract infection

V VSD ventricular septal defect

Vx vertex

W Wt weight

Y Yrs years

other 1/24 or 1hr one hour

1/7 or 1d one day 1/52 or 1wk one week 1/12 or 1mth one month

32/40 (no) weeks gestation

&-ile percentile

< less than

> greater than

= equal to

+ plus

- minus

-ve negative

+ve positive


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Bibliography

Carpenito-Moyet LJ, 2009, Nursing care plans and documentation 5th edition, Lippincott

Williams and Wilkins

Cheevakasemsook A, Chapman Y, Francis K, Davies C, 2006, The study of nursing

documentation complexities International Journal of Nursing Practice 12: 366�374

College and Association of Registered Nurses of Alberta (CARNA), 2006, Documentation

guidelines for registered nurses Edmonton, AB

College of Nurses of Ontario, 2008, Practice Standard: Documentation

College of Registered Nurses of British Columbia, 2008, Practice Standard: Documentation

College of Registered Nurses of British Columbia, 2013, Practice Support: Nursing

Documentation

College of Registered Nurses of Nova Scotia, 2012, Documentation Guidelines for Registered

Nurses

Hanson JL, Stephens MB, Pangaro LN, Gimber RW, 2012, Quality of outpatient clinical notes:

a stakeholder definition derived through qualitative research, BMC Health Services

Research 12:407

Johnson, M, Jefferies D, Langdon, R, 2010, The Nursing and Midwifery Content Audit Tool

(NMCAT): a short nursing documentation audit tool, Journal of Nursing Management, 18,

832�845

Mosby's Medical Dictionary, 8th edition, 2009, Elsevier

NSW Health, 2014, Benchmark for documentation and communication, Essentials for care:

Paediatric domain: Paediatric family-centred care domains and care outcomes.

Nursing and Midwifery Board of Australia

- National competency standards for the midwife (2006)

- National competency standards for the registered nurse (2006)

- Code of professional conduct for midwives in Australia (2008)

- Code of ethics for midwives in Australia (2008)


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- Code of professional conduct for nurses in Australia (2008)

- Code of Ethics for Nurses in Australia (2008)

- Professional boundaries for midwives (2010)

All available at: http://www.nursingmidwiferyboard.gov.au.

Potter PA, Perry, AG, 2010, Canadian fundamentals of nursing, Toronto ON: Elsevier Canada

Prideaux A, 2011, Issues in nursing documentation and record-keeping practice British

Journal of Nursing Volume 20 (22)

Rosenbloom ST, Denny JC, Xu H, Lorenzi N, Stead WW, Johnson KB, 2010, Data from clinical

notes: a perspective on the tension between structure and flexible documentation,

Journal American Medical Information Association 18: 181-186

Sydney South West Area Health Service, 2009, Documentation: Nursing and Midwifery

Services � Minimum standards for documentation

Taylor H, 2003, Professional issues: An exploration of the factors that affect nurses� record

keeping British Journal of Nursing 12 (12)

VAMCHN Competency Standards for the Maternal and Child Health Nurse in Victoria (2010)

Available via the VAMCHN website: http://www.vamchn.org.au/