standards of psychiatric mental
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STANDARDS OF PSYCHIATRIC MENTAL
HEALTH NURSING PRACTICE
Standards Of Practice
Standard 1. ASSESSMENT
The psychiatric mental health registered nurse collects comprehensive health data
that is pertinent the patients health or situation.
Rationale
The psychiatric mental health registered nurse uses linguistically and culturally effective
communication skills, interviewing, behavioral observation, record review and collection
of collateral information to make sound clinical assessments.
Measurement Criteria
The Psychiatric-Mental Health Registered Nurse:
Collects data in a systematic and ongoing process.
Involves the patient, family, other healthcare providers, and environment, as appropriate, in
holistic data collection.
Demonstrates effective clinical interviewing skills that facilitate development of a therapeutic
alliance.
Prioritizes data collection activities based on the patients immediate condition or anticipated
needs of the patient or situation. The data may include but is not limited to the patients:
Central complaint, focus or concern and symptoms of major psychiatric disorders.
History and presentation regarding suicidal, violent, and self-mutilating behaviors
to assess level of risk.
History of reliability with regard to patients verbal agreement to seek professional assistance
prior to engaging in behaviors dangerous to self or others.
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Pertinent family history of psychiatric disorders, substance abuse and othermental health
issues.
Evidence ofabuse or neglect.
Stressors, contributing factors and coping strategies.
Scope & Standards Draft Revision 2006
1. Demographic profile and history of health patterns, illnesses and past treatments and level of
adherence and effectiveness.
2. Actual or potential barriers to adherence to recommended or prescribed treatment.
3. Health beliefs and practices.
4. Religious and spiritual beliefs and practices.
5. Cultural, racial and ethnic identity and practices.
6. Physical, developmental, cognitive, mental status, emotional health concerns and
neurological assessment.
7. Daily activities, personal hygiene, occupational functioning, functional health status and
social roles, including work, sleep and sexual functioning.
8. Economic, political, legal, and environmental factors affecting health.
9. Significant support systems and community resources including what has been available and
underutilized.
10. Knowledge, satisfaction, and motivation to change, related to health.
11. Strengths and competencies that can be used to promote health.
12.Current and past medications, both prescribed and over-the-counter inclusive of herbs,
alternative medications, vitamins, or nutritional supplements.
13. Medication interactions and history of side effects and past efficacy.
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14. History and patterns of alcohol and substance abuse including type, amount, most recent
use and withdrawal symptoms.
15. Complementary therapies used to treat health and mental illness and outcomes.
16. Uses appropriate evidence-based assessment techniques and instruments in collecting
pertinent data.
17. Uses analytical modes and problem-solving techniques.
18. Ensures that appropriate consents, as determined by regulations and policies, are obtained
to protect patient confidentiality and support the patients rights in the process of data
gathering.
19.Synthesizes available data, information, and knowledge relevant to the situation to identify
patterns and variances.
20.Uses therapeutic principles to understand and interpret the patients emotion, thoughts and
behaviors.
21.Documents relevant data in a retrievable format.
1 Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice
NurseThe APRN-PMH:
Employs evidence-based clinical practice guidelines to guide screening and diagnostic
activities as available and appropriate. Performs physical and comprehensive mental health
assessment. Initiates and interprets diagnostic tests and procedures relevant to the patients
current status. Conducts a multigenerational family assessment, including medical and
psychiatric history. Assesses the interface among the individual, family, community, and social
systems and their relationship to mental health functioning.
Standard 2. DIAGNOSIS
The psychiatric-mental health registered nurse analyzes the assessment data in
determining diagnoses or problems including level of risk.
Rationale
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Through comprehensive and focused assessment and data analysis the psychiatric mental
health registered nurse identifies patient needs related to actual or potential psychiatric
disorders, mental health problems, and potential co-morbid physical illnesses.
Measurement Criteria
The psychiatric mental health registered nurse:
Derives the diagnosis or problems from the assessment data, Identifies actual or potential risks
to the patients health and safety and/or barriers to mental and physical health which may
include but is not limited to interpersonal, systematic, or environmental circumstances.
Develops diagnoses or problem statements that conform, or are congruent with, available and
accepted classifications systems. Validates the diagnosis or problems with the patient,
significant others and other health care clinicians. Documents diagnoses or problems in a
manner that facilitates the determination of the expected outcomes and plan.
Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice
Registered NurseThe APRN-PMH:
Systematically compares and contrasts clinical findings with normal and abnormal variations
and developmental events in formulating a differential diagnosis. Develops a differential
diagnosis derived from the collection and synthesis of assessment data, and applies
standardized taxonomy systems to the diagnosis of mental health problems and psychiatric
disorders utilizing current DSM & ICD Taxonomy. Utilizes complex data and information
obtained during interview, examination and diagnostic procedures in identifying diagnosis.
Documents the diagnosis. Identifies long-term effects of psychiatric disorders on mental,
physical and socialhealth. Evaluates the health impact of life stressors, traumatic events and
situational crises within the context of the family cycle. Evaluates the impact of the course of
psychiatric disorders and mental health problems on quality of life and functional status.
Assists staff in developing and maintaining competency in the diagnostic process.
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Standard 3. OUTCOMES IDENTIFICATION
The psychiatric mental health registered nurse identifies expected outcomes for a plan
individualized to the patient or to the situation.
Rationale
Psychiatric mental health registered nurses provide nursing care to influence positive. patient
outcomes including the achievement of individualized mental and physical health goals.
1Measurement Criteria
The psychiatric mental health registered nurse: Derives culturally appropriate expected
outcomes from the diagnosis. Involves the patient, family, and other healthcare providers in
formulating expected outcomes when possible and appropriate. Considers associated risks,
benefits, costs, current scientific evidence, and clinical expertise when formulating expected
outcomes. Defines expected outcomes in terms of the patient, patient values, ethical
considerations, environment or situation with such consideration as associated risks,benefits
and costs, and current scientific evidence.Develops expected outcomes that provide direction
for continuity of care. Documents expected outcomes as measurable goals. Includes a time
estimate for attainment of expected outcomes.
Modifies expected outcomes based on changes in the status of the patient or evaluation of the
situation.
Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice
Registered NurseThe APRN-PMH:
Identifies expected outcomes that incorporate scientific evidence and are achievable through
implementation of evidence-based practices.
Identifies expected outcomes that incorporate cost and clinical effectiveness, patient
satisfaction, and continuity and consistency among providers.
Supports the use of clinical guidelines linked to positive patient outcomes.
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Standard 4. PLANNING
The psychiatric mental health registered nurse develops a plan that prescribesstrategies
and alternatives to attain expected outcomes.
1 Rationale
2 A plan of care is used to systematically guide therapeutic interventions and document
progress.
Measurement Criteria
The psychiatric mental health registered nurse:
Develops the plan in collaboration with the patient, family, and other health care providers
when appropriate.
Prioritizes elements of the plan based on the assessment of the patients level of risk for
potential harm to self or others and safety needs.
Includes strategies within the plan that address each of the identified diagnoses or issues, which
may include strategies for promotion and restoration of health and prevention of illness, injury,
and disease.
Assists patients in securing treatment or services in the least restrictive environment.
Includes an implementation pathway or timeline within the plan.
Provides for continuity within the plan.
Utilizes the plan to provide direction to other members of the health care team.
Documents the plan using standardized language or recognized terminology.
Defines the plan to reflect current statutes, rules and regulations, and standards.
Develops the plan to reflect the use of available research evidence.
Considers the economic impact of the plan.
Modifies the plan based on ongoing assessment of the patients response and other outcome
indicators.
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1 Additional Measurement Criteria for the Psychiatric Mental Health AdvancedPractice
Registered NurseThe APRN-PMH:
Within the plan, identifies assessment, diagnostic strategies, and therapeutic interventions to
address mental health problems and psychiatric disorders that reflect current evidence,
including data, research, literature, and expert clinical knowledge.
Plans care to minimize the development of complications and promote function and quality of
life using treatment modalities such as, but not limited to, behavioral therapies, psychotherapy
and psychopharmacology.
Selects or designs strategies to meet the multifaceted needs of complex patients.
Includes synthesis of patients values and beliefs regarding nursing and medical therapies
within the plan.
Standard 5. IMPLEMENTATION
The psychiatric mental health registered nurse implements the identified plan.
Measurement Criteria
The psychiatric mental health registered nurse:
Implements the plan in a safe and timely manner.
Documents implementation and any modifications, including changes or omissions of the
identified plan.
Utilizes evidence based interventions and treatments specific to the diagnosis or problem.
Utilizes community resources and systems to implement the plan.
Collaborates with nursing colleagues and others to implement the plan.
Manages psychiatric emergencies by determining the level of risk and initiating and
coordinating effective emergency care.
Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice
Registered Nurse.The APRN-PMH:
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Facilitates utilization of systems and community resources to implement the plan. Supports
collaboration with nursing colleagues and other disciplines to implement the plan. Incorporates
new knowledge and strategies to initiate change in nursing care practices if desired outcomes
are not achieved. Implements the plan using principles and concepts of project or systems
management.
Standard 5 A. COORDINATION OF CARE
The psychiatric mental health registered nurse coordinates care delivery.
Measurement Criteria
The psychiatric mental health registered nurse:
Coordinates implementation of the plan.
Documents the coordination of care.
Additional Measurement Criteria for Psychiatric Mental Health Advanced Practice
Registered NurseThe APRN-PMH:
Provides leadership in the coordination of multidisciplinary health care for integrated delivery
of patient care services.
Synthesizes data and information to prescribe necessary system and community support
measures, including environmental modifications.
Coordinates system and community resources that enhance delivery of care across continuums.
Assists patients in getting financial assistance as needed to maintain appropriate care.
Standard 5 B. HEALTH TEACHING AND HEALTH PROMOTION
The psychiatric mental health registered nurse employs strategies to promote health and
a safe environment.
Rationale
The psychiatric mental health registered nurse, through health teaching, promotes the patients
personal and social integration and assists the patient in achieving satisfying, productive, and
health patterns of living.
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Measurement Criteria
The psychiatric mental health registered nurse
Uses health promotion and health teaching methods appropriate to the situation, patients
developmental level, learning needs, readiness, ability to learn, language preference and
culture.
Provides health teaching related to the patients needs and situation that may include, but is not
limited to, mental health problems and psychiatric disorders, treatment regimen, coping skills,
relapse prevention, self-care activities, resources, conflict management, problem-solving skills,
stress management and relaxation techniques, a crisis management. Integrates current
knowledge and research regarding psychotherapeutic educational strategies and content.
Engages consumer alliances and advocacy groups, as appropriate, in health teaching and health
promotion activities. Identifies community resources to assist consumers in using prevention
and mental health care services appropriately. Seeks opportunities for feedback and evaluation
of the effectiveness of strategies utilized. Provides anticipatory guidance to individuals and
families to promote mental health and to prevent or reduce the risk of psychiatric disorders.
1 Additional Measurement Criteria for the Psychiatric Mental Health AdvancedPractice
Registered Nurse.The APRN-PMH:
Educates patients and significant others about intended effects and potential adverse effects of
treatment options.
Provides education to individuals, families, and groups to promote knowledge, understanding
and effective management of overall health maintenance, mental health problems and
psychiatric disorders.
Uses knowledge of health beliefs, practices, evidence-based findings, and epidemiological
principles, along with the social, cultural, and political issues that affect mental health in an
identified community to develop health promotion strategies.
Synthesizes empirical evidence on risk behaviors, learning theories, behavioral change
theories, motivational theories, epidemiology, and other related theories and frameworks when
designing health information and patient education.
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Designs health information and patient education appropriate to the patients developmental
level, learning needs, readiness to learn, and cultural values and beliefs.
Evaluates health information resources, such as the Internet, within the area of practice for
accuracy, readability, and comprehensibility to help patients access quality health information.
Standard 5C. MILIEU THERAPY
The psychiatric mental health registered nurse provides, structures, and maintains asafe
and therapeutic environment in collaboration with the patients, families andother health
care clinicians.
Rationale
The therapeutic environment consists of the physical environment, social structures, and the
philosophy of care and treatment that provides safety at points of crisis and supports the
patients ability to use new adaptive coping strategies and available resources.
Measurement Criteria
The psychiatric mental health registered nurse:
Orients the patient and family to the care environment including the physical environment, the
roles of different health care team providers in their care.
1 involved in the treatment and care delivery processes, schedules of events pertinent to their
care and treatment, and expectations regarding behaviors. Orients the patient to their rights and
responsibilities particular to the treatment or care environment.
Conducts ongoing assessments of the patient in relationship to the environment to guide
nursing interventions in maintaining a safe environment and patient safety.
Selects specific activities that meet the patients physical and mental health needs for
meaningful participation in the milieu and promoting personal growth.
Ensures that the patient is treated in the least restrictive environment necessary to maintain the
safety of the patient and others.
Informs the patient in a culturally competent manner about the need for the limits and the
conditions necessary to remove the restrictions.
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Provides the patient with the opportunity to discuss their illness experience with The
psychiatric mental health nurse to promote support, validation and prevention of complications.
Standard 5 D. PHARMACOLOGICAL, BIOLOGICAL AND COMPLEMENTARY
INTERVENTIONS
The psychiatric-mental registered nurse uses knowledge of pharmacological, biological
and complementary interventions and applies clinical skills to restore thepatients health
and prevent further disability.
Measurement Criteria
The psychiatric mental health registered nurse:
Applies current research findings to guide nursing actions related to pharmacology, other
biological therapies, and complementary therapies.
Assesses patients response to biological interventions based on current knowledge of
pharmacological agents intended actions, interactive effects, potential untoward effects and
therapeutic doses.
Includes health teaching for medication management to support patients in managing their own
medications, and adherence to prescribed regimen.
Educates on information about mechanism of action, intended effects, potential adverse effects
of the proposed prescription, ways to cope with transitional side effects and other treatment
options, including no treatment.
Directs interventions toward alleviating untoward effects of biological interventions.
Communicates observations about the patients response to biological interventions are to
other health clinicians.
Standard 5E. PRESCRIPTIVE AUTHORITY AND TREATMENT The APRN-PMH
prescribes or recommends, pharmacological agents for patients with mental health
problems and psychiatric disorders based on individualcharacteristics, such as culture,
ethnicity, gender, religious beliefs, age and physicalhealth problems.
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Measurement Criteria
Conducts a thorough assessment of past medical trials, side effects, efficacy and patient
preference. Prescribes or recommends pharmacological agents based on research evidence and
knowledge of psychopathology, neurobiology, physiology, expected therapeutic actions,
anticipated side effects and courses of action. Prescibes or recommends psychotropic and
related medications based on clinical indicators of patient status. Assesses a reasoned balance
of risk and benefits, including results of diagnostic and lab tests as appropriate, to treat
symptoms of psychiatric disorders and improve functional status.
Provides health teaching about mechanism of action, intended effects, potential adverse effects
of the proposed prescription, ways to cope with transitional side effects and other treatment
options, including no treatment.
Educates and assists the patient in selecting the appropriate use of complementary and
alternative therapies. Evaluates therapeutic and potential adverse effects of pharmacological
and non pharmacological treatments. Evaluates pharmacological outcomes by utilizing standard
symptom measurements and patient report to determine efficacy.
Adjusts medications based on continual monitoring in collaboration with patient.
Standard 5F. PSYCHOTHERAPY
The Psychiatric Mental Health Advanced Practice Registered Nurse conducts individual,
couples, group, and/or family psychotherapy using evidence-based psychotherapeutic
frameworks, interpersonal transactions and nurse-patienttherapeutic relationship.
Measurement Criteria
The APRN-PMH:
Uses knowledge of personality theory, growth and development, psychology, neurobiology,
psychopathology, social systems small-group and family dynamics, stress and adaptation, and
theories and best available research evidence to select therapeutic methods based on the
patients needs.
Structures the therapeutic contract to include, but not limited to:
Purpose, goals, and expected outcomes
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Time, place and frequency of therapy
Participants involved in therapy
Confidentiality and appropriate written release of information
Availability and means of contacting therapist
Responsibilities of both patient and therapist
Fees and payment schedule
Cancellations/alteration in schedule policy
Utilizes interventions that promote mutual trust to build a therapeutic treatment alliance.Empowers patients to be active participants in treatment.
Applies therapeutic communication strategies based on theories and research evidence to
reduce emotional distress, facilitate cognitive and behavioral change and foster personal
growth. Uses self-awareness of emotional reactions and behavioral responses to others to
enhance the therapeutic alliance.
Analyzes the impact of duty to report and other advocacy actions on the therapeutic alliance.
Arranges for the provision of care in the therapists absence.
Applies ethical and legal principles to the treatment of patients with mental health problems
and psychiatric disorders.
Makes referrals when it is determined that the patient will benefit from a transition of care or
consultation due to change in clinical condition.
Evaluates effectiveness of interventions is relation to outcomes using standardized methods as
appropriate.
Monitors outcomes of therapy and adjusts plan of care when indicated.
Therapeutically concludes the nurse-patient relationship and transitions the patient to
other levels of care, when appropriate.
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Identifies and maintains professional boundaries to preserve the integrity of thetherapeutic
process.
Standard 5G. CONSULTATION
The psychiatric mental health advanced practice nurse provides consultation to influence
the identified plan, enhance the abilities of other clinicians to provide services for patients
and effect change.
Measurement Criteria
The APRN-PMH:
Synthesizes clinical data, theoretical frameworks, and evidence when providing consultation.Initiates consultation at the request of the consultee.
Establishes a working alliance with the patient or consultee based on mutual respect and role
responsibilities.
Facilitates the effectiveness of a consultation by involving the stakeholders in the decision-
making process.
Communicates consultation recommendations that influence the identified plan, facilitate
understanding by involved stakeholders , enhance the work of others, and effect change.
Clarifies that implementation of system changes or changes to the plan of care remain the
consultees responsibility.
Standard 6. EVALUATION
The psychiatric mental health registered nurse evaluates progress toward attaining
expected outcomes.
Measurement Criteria
The psychiatric mental health registered nurse: Conducts a systematic, ongoing, and
criterion-based evaluation of the outcomes inrelation to the structures and processes prescribed
by the plan and indicated timeline.
Involve the patient, family or significant others, and other health care clinicians in the
evaluation process.
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Documents results of the evaluation.
Evaluates the effectiveness of the planned strategies in relation to patient responses and the
attainment of the expected outcomes.
Uses on going assessment data to revise the diagnoses, outcomes, the plan and the
implementation as needed.
Disseminates the results to the patient and others involved in the care or situation, as
appropriate, in accordance with state and federal laws and regulations.
Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice
Nurse: The APRN-PMH:
Evaluates the accuracy of the diagnosis and effectiveness of the interventions in relationship to
thepatients attainment of expected outcomes.
Synthesizes the results of the evaluation analyses to determine the impact of the plan on the
affected patients, families, groups, communities, and institutions.
Uses the results of the evaluation analyses to make or recommend process or structural
changes, including policy, procedure, or protocol documentation, as appropriate Psychiatric
Mental Health NursingScope & Standards Draft Revision 2006
STANDARDS OF PROFESSIONAL PERFORMANCE
Standard 7. QUALITY OF PRACTICE
The psychiatric mental health registered nurse systematically enhances the quality
and effectiveness of nursing practice.
Measurement Criteria
The psychiatric-mental health registered nurse:
Demonstrates quality by documenting the application of the nursing process in a responsible,
accountable, and ethical manner.Uses the results of quality improvement activities to initiate
changes in nursing practice and in the healthcare delivery system.
Uses creativity and innovation in nursing practice to improve care delivery.
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Incorporates new knowledge to initiate changes in nursing practice if desired outcomes are not
achieved.
Obtains and maintains certification in psychiatric mental health nursing.
Participates in quality improvement activities. Such activities may include:
Identifying aspects of practice important for quality monitoring.
Using indicators developed to monitor quality and effectiveness of nursing practice.
Collecting data to monitor quality and effectiveness of nursing practice.
Analyzing quality data to identify opportunities for improving nursing practice.
Formulating recommendations to improve nursing practice or outcomes.
Implementing activities to enhance the quality of nursing practice.
Developing, implementing, and evaluating policies, procedures and/orguidelines to improve the
quality of practice.
Participating on interdisciplinary teams to evaluate clinical care or health services.
Participating in efforts to minimize costs and unnecessary duplication.
Analyzing factors related to safety, satisfaction, effectiveness, and cost/benefit options.
Analyzing organizational systems for barriers
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Scope & Standards Draft Revision 2006
Implementing processes to remove or decrease barriers within organizational systems.
Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice
Nurse.
The APRN-PMH:
Obtains and maintains professional certification if available in the area of expertise.
Designs quality improvement initiatives.
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Implements initiatives to evaluate the need for change.
Evaluates the practice environment and quality of nursing care rendered in relation to existing
evidence, identifying opportunities for the generation and use of research.
Standard 8. EDUCATION
The psychiatric mental health registered nurse attains knowledge and competency that
reflects current nursing practice.
Measurement Criteria
The psychiatric mental health registered nurse:
Participates in ongoing educational activities related to appropriate knowledge bases and
professional issues.
Demonstrates a commitment to lifelong learning through self-reflection and inquiry to identify
learning needs.
Seeks experiences that reflect current practice in order to maintain skills and competence in
clinical practice or role performance.
Acquires knowledge and skills appropriate to the specialty area, practice setting,role, or
situation.
Maintains professional records that provide evidence of competency and life long learning.
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Scope & Standards Draft Revision 2006
Seeks experiences and formal and independent learning activities to maintain and
develop clinical and professional skills and knowledge.
Additional Measurement Criteria for the Psychiatric Mental Health Advanced
Practice Nurse:
The APRN- PMH:
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Uses current healthcare research findings and other evidence to expand clinical knowledge,
enhance role performance, and increase knowledge of professional issues.
Standard 9: PROFESSIONAL PRACTICE EVALUATION
The psychiatric mental health registered nurse evaluates his/her own practice in relation
to the professional practice standards and guidelines, relevant statutes, rules, and
regulations.
Measurement Criteria
The psychiatric mental health registered nurse:
Demonstrates the application of knowledge of current practice standards, guidelines, statutes,rules, and regulations.
Provides age appropriate care in a culturally and ethnically sensitive manner.
Engages in self-evaluation of practice on a regular basis, identifying areas of strength as well as
areas in which professional development would be beneficial. Obtains informal feedback
regarding ones own practice from patients, peers, professional colleagues, and others.
Participates in systematic peer review as appropriate.
Takes action to achieve goals identified during the evaluation process.
Provides rationale for practice beliefs, decisions, and actions as part of the informal and formal
evaluation processes.
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Scope & Standards Draft Revision 2006
Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice
Registered Nurse:
The APRN-PMH:
Engages in a formal process seeking feedback regarding ones own practice from patients,
peers, professional colleagues, and others.
Standard 10. COLLEGIALITY
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The psychiatric mental health registered nurse interacts with and contributes to the
professional development of peers and colleagues.
Measurement Criteria
The psychiatric-mental health registered nurse:
Shares knowledge and skills with peers and colleagues as evidenced by such activities as
patient care conferences or presentations at formal or informal meetings.
Provides peers with feedback regarding their practice and/or role performance.
Interacts with peers and colleagues to enhance ones own professional nursing practice and/or
role performance.
Maintains compassionate and caring relationships with peers and colleagues.
Contributes to an environment that is conducive to the education of healthcare professionals.
Contributes to a supportive and healthy work environment.
Additional Measurement Criteria for the psychiatric mental health advanced practice
nurse.
The APRN-PMH:
Models expert practice to interdisciplinary team members and healthcare consumers.
Mentors other registered nurses and colleagues as appropriate.
Participates with interdisciplinary teams that contribute to role development and advanced
nursing practice and health care.
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Scope & Standards Draft Revision 2006
Standard 11: COLLABORATION
The psychiatric mental health registered nurse collaborates with patients, family and
others in the conduct of nursing practice.
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Measurement Criteria
The psychiatric-mental health registered nurse:
Communicates with patient, family, and healthcare providers regarding patient care and the
nurses role in the provision of that care.
Collaborates in creating a documented plan focused on outcomes and decisions related to care
and delivery of services that indicates communication with patients, families, and others.
Partners with others to effect change and generate positive outcomes through knowledge of the
patient or situation.
Documents referrals, including provisions for continuity of care.
Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice
Registered Nurse.
The APRN-PMH:
Partners with other disciplines to enhance patient care through interdisciplinary activities, such
as education, consultation, management, technological development, or research opportunities.
Facilitates an interdisciplinary process with other members of the healthcare team.
Documents plan of care communications, rationales for plan of care changes, and collaborative
discussions to improve patient care.
Standard 12: ETHICS
The psychiatric mental health registered nurse integrates ethical provisions in allareas of
practice.
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Scope & Standards Draft Revision 2006
Measurement Criteria
The psychiatric mental health registered nurse:
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Uses the Code of Ethics for Nurses with Interpretive Statements (ANA, 2001) to guide practice.
Delivers care in a manner that preserves and protects patient autonomy, dignity and rights.
Maintains patient confidentiality within legal and regulatory parameters.
Serves as a patient advocate assisting patients in developing skills for self advocacy.
Maintains a therapeutic and professional patientnurse relationship with appropriate
professional role boundaries and does not promote or engage in intimate, sexual, or business
relationships with current or former patients.
Monitors and carefully manages self-disclosure therapeutically.
Demonstrates a commitment to practicing self-care, managing stress, and connecting with self
and others.
Contributes to resolving ethical issues of patients, colleagues, or systems as evidenced in such
activities as participating on ethics committees.
Reports illegal, incompetent, or impaired practices.
Additional Measurement Criteria for the Psychiatric Mental Health Advanced
Practice Nurse
The APRN-PMH:
Informs the patient of the risks, benefits, and outcomes of healthcare regimens.
Participates in interdisciplinary teams that address ethical risks, benefits, and outcomes.
Standard 13: RESEARCH
The psychiatric mental health registered nurse integrates research findings intopractice.
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Scope & Standards Draft Revision 2006
Measurement Criteria
The psychiatric-mental health registered nurse:
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Utilizes the best available evidence, including research findings, to guide practice decisions.
Actively participates in research activities at various levels appropriate to the nurses level of
education and position. Such activities may include:
Identifying clinical problems specific to psychiatric-mental health nursing research (patient
care and nursing practice).
Participating in data collection (surveys, pilot projects, formal studies)
Participating in a formal committee or program.
Sharing research activities and/or findings with peers and others
Conducting research.
Critically analyzing and interpreting research for application to practice.
Using research findings in the development of policies, procedures, and standards of practice in
patient care.
Incorporating research as a basis for learning.
Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice
Nurse The APRN-PMH:
Contributes to nursing knowledge by conducting, critically appraising or synthesizing research
that discovers, examines and evaluates knowledge, theories, criteria, and creative approaches to
improve healthcare practice.
Formally disseminates research findings through activities such as presentations,publications,
consultation, and journal clubs.
Demonstrates leadership in promoting a culture that consistently integrates the best available
research evidence into practice.
STANDARD 14. RESOURCE UTILIZATION
The psychiatric mental health registered nurse considers factors related to
safety,effectiveness, cost, and impact on practice in the planning and delivery of nursing
services.
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7Measurement Criteria
The psychiatric-mental health registered nurse:
Evaluates factors such as safety, effectiveness, availability, cost and benefits, efficiencies, and
impact on practice, when choosing practice options that would result in the same expected
outcome.
Assists the patient and family in identifying and securing appropriate and available services to
address health-related needs.
Assigns or delegates tasks, based on the needs and condition of the patient, potential for harm,
stability of the patients condition, complexity of the task, and predictability of the outcome.
Assists the patient and family in becoming informed consumers about the options, costs, risks,
and benefits of treatment and care.
Additional Measurement Criteria for the Psychiatric Mental Health Advanced Practice
Nurse: The APRN-PMH:
Utilizes organizational and community resources to formulate multidisciplinary or
interdisciplinary plans of care.
Develops innovative solutions for patient care problems that address effective resource
utilization and maintenance of quality.
Develops evaluation strategies to demonstrate quality, cost effectiveness, cost benefit, and
efficiency factors associated with nursing practice.
STANDARD 15. LEADERSHIP
The psychiatric mental health registered nurse provides leadership in the professional
practice setting and the profession.
Measurement Criteria
The psychiatric-mental health registered nurse: Engages in teamwork as a team player and a
team builder.
Works to create and maintain healthy work environments in local, regional, national, or
international communities.
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Displays the ability to define a clear vision, the associated goals, and a plan to implement and
measure progress.
Demonstrates a commitment to continuous, life long learning for self and others.
Teaches others to succeed by mentoring and other strategies.
Exhibits creativity and flexibility through times of change.
Demonstrates energy, excitement, and a passion for quality work.
Willingly accepts mistakes by self and others thereby creating a culture in which risk-taking is
not only safe, but expected.
Inspires loyalty through valuing of people as the most precious asset in an organization.
Directs the coordination of care across settings and among caregivers, including oversight of
licensed and unlicensed personnel in any assigned or delegated tasks.
Serves in key roles in the work setting by participating on committees, councils, and
administrative teams.
Promotes advancement of the profession through participation in professional organizations.
Additional Measurement Criteria for the Psychiatric Mental health Advanced Practice
Nurse The APRN-PMH:
Utilizes ethical principles to create a system of advocacy for access and parity for mental health
problems, psychiatric disorders, and addiction services.
Influences health policy to reduce the impact of stigma on services for prevention and treatment
of mental health problems and psychiatric disorders.
Works to influence decision-making bodies to improve patient care.
Provides direction to enhance the effectiveness of the healthcare team.
Initiates and revises protocols or guidelines to reflect evidence-based practice, to reflect
accepted changes in care management, or to address emerging problems.
Promotes communication of information and advancement of the profession through writing,
publishing, and presentations for professional or lay audiences.
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Designs innovations to effect change in practice and improve health outcomes.
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DOCUMENTATION
D E F I N I T I O N
Documentation is any written or electronically generated information about a client that
describes the care or service provided to that client. Health records may be paper documents or
electronic documents, such as electronic medical records, faxes, e-mails, audio or video tapes
and images. Through documentation, nurses communicate their observations, decisions, actions
and outcomes of these actions for clients. Documentation is an accurate account of what
occurred and when it occurred. Nurses may document information pertaining to individual
clients or groups of clients.
Individual Clients : When caring for an individual client (which may include the clients
family), the nurses documentation provides a clear picture of the status of the client, the
actions of the nurse, and the client outcomes.
Nursing documentation clearly describes: an assessment of the clients health status, nursing
interventions carried out, and the impact of these interventions on client outcomes; a care plan
or health plan reflecting the needs and goals of the client; needed changes to the care plan;
information reported to a physician or other health care provider and, when appropriate, that
providers response; and advocacy undertaken by the nurse on behalf of the client.
Groups of Clients
When providing service to groups of clients (e.g., therapy groups, public health programs),
service records (or an equivalent) are used to document the service provided and overall
observations pertaining to the group. Similar to documentation for individuals, documentation
for groups reflects the needs assessment, plans, actions taken, and evaluation of the group
outcomes.
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Documentation of services provided to a group of clients describes:
The purpose and goal of the group
The criteria for participation
Intervention activities and group processes and
An evaluation of group outcomes.
N U R S I N G D O C U M E N T A T I O N
Pertinent information about individual clients within the group is documented on individual
client health records, not on the group service record. When charting on an individual client
health record, names of other group members are not identified.
R E A S O N S F O R D O C U M E N T A T I O N
To facilitate communication Through documentation, nurses communicate to other nurses and care providers their
assessments about the status of clients, nursing interventions that are carried out and the
results of these interventions.
Documentation of this information increases the likelihood that the client will receiveconsistent and informed care or service.
Thorough, accurate documentation decreases the potential for miscommunication anderrors. While documentation is most often done by nurses and care providers, there are
situations where the client and family may document observations or care provided in
order to communicate this information with members of the health care team.
To promote good nursing care Documentation encourages nurses to assess client progress and determine which
interventions are effective and which are ineffective, and identify and document
changes to the plan of care as needed.
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Documentation can be a valuable source of data for making decisions about funding andresource management as well as facilitating nursing research, all of which have the
potential to improve the quality of nursing practice and client care.
Individual nurses can use outcome information or information from a critical incident toreflect on their practice and make needed changes based on evidence.
To meet professional and legal standardsDocumentation is a valuable method for demonstrating that, within the nurse-client
relationship, the nurse has applied nursing knowledge, skills and judgment according to
professional standards. The nurses documentation may be used as evidence in legal
proceedings such as lawsuits, coroners inquests, and disciplinary hearings through professional
regulatory bodies. In a court of law, the clients health record serves as the legal record of the
care or service provided. Nursing care and the documentation of that care will be measured
according to the standard of a reasonable and prudent nurse with similar education and
experience in a similar situation.
T O O L S F O R D O C U M E N T A T I O N
There are many tools used for client documentation, including worksheets and kardexes, client
care plans, flowsheets and checklists, care maps, clinical pathways and monitoring strips. These
tools may be written or electronic in format. Regardless of the tool used, pertinent information
specific to an individual client resides within the clients health record.
Worksheets and kardexes
Nurses use worksheets to organize the care they provide, and to manage their time and multiple
priorities.
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Kardexes are used to communicate current orders, upcoming tests or surgeries, special diets or
the use of aids for independent living specific to an individual client (College of Nurses of
Ontario, 2002). If a paper format is used,entries may be erasable as long as the assessment,
nursing interventions carried out and the impact of these interventions on client outcomes are
documented in the permanent health record.
N U R S I N G D O C U M E N T A T I O N
Documentation of the clients care plan, it is kept as part of the permanent record.
Client care plans
Care plans are outlines of care for individual clients and make up part of the permanent health
record. Care plans are written in ink (unless electronic), up-to-date and clearly identify the
needs and wishes of the client.
Flow sheets and checklists
Flow sheets and checklists are used to document routine care and observations that are recorded
on a regular basis (e.g., activities of daily living, vital signs, intake and output). Flow sheets and
checklists are part of the permanent health record, and can be used as evidence in legal
proceedings (College of Nurses of Ontario, 2002). Symbols (e.g., check marks) may be used on
flow sheets or checklists as long as it is clear who performed the assessment or intervention and
the meaning of each of the symbols is identified in agency policy.
Care maps and clinical pathways
Care maps and clinical pathways outline what care will be done and what outcomes are
expected over a specified time frame for a usual client within a case type or grouping. Nurses
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individualize care maps and clinical pathways to meet clients specific needs (e.g., by making
changes to items that are not appropriate). If the status of clients varies from that outlined on
the care map or clinical pathway at a particular time period, the variance is documented,
including the reasons and action plan to address it.
Monitoring strips
Monitoring strips (e.g., cardiac, fetal or thermal monitoring; blood pressure testing) provide
important assessment data and are included as part of the permanent health record.
I N C I D E N T R E P O R T S
Agencies often have policies that require nurses to complete incident reports following unusual
occurrences, such as medication errors or harm to clients, staff or visitors. Regardless of
whether incident reports are used, nurses have a professional obligation to document the actual
care provided to an individual in the clients health record.
Incident reports are administrative risk management tools to track trends and patterns about
groups of clients over time. Incident reports are to be used for quality assurance not punitive
purposes. Incident reports completed in hospital based agencies are protected from disclosure
in legal proceedings in section 51 of the Evidence Act (2001). Therefore, they are retained
separately from the health record and no reference to an incident report is made in the health
record to protect the incident report from subpoena.
British Columbia Health Care Risk Management Society (2002) recommends the following:
Ensure that the facts of the incident are recorded separately from opinions about the cause of
the incident and from any quality assurance follow-up information. Some organizations have a
two-part incident report with follow-up and recommendations separate from the rest of the
report.
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Never promise a patient/family a copy of an incident report or of any report arising out of
quality assurance investigation - section 51 of the Evidence Act prohibits this.
N U R S I N G D O C U M E N T A T I O N
Directives for Documentation
Requirements for documentation and the sharing, retention and disposal of this information are
drawn from several sources: statutory regulations; Standards of Practice; agency policies and
procedures; and legal principles.
S T A T U T O R Y R E G U L A T I O N S
There are no laws in BC stating specifically how and what nurses must document. Agencies
generally develop documentation policies which reflect provincial and federal government
statutes and/or other relevant documents.
The following statutes and documents guide policy in most B.C. agencies:
British Columbia Coroners Act Health Professions Act
Child, Family and Community Service Act Hospital Act
Controlled Drug and Substances Act (Federal) Health Care (Consent) and Facilities Act
Electronic Transactions Act Limitation Act
Evidence Act Medical Practitioners Act
Freedom of Information and Protection of Privacy Act Mental Health Act
Health Act
Other Relevant Documents
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S T A N D A R D S O F P R A C T I C E
Professional Standards for Registered Nurses and Nurse Practitioners
A standard is a desired and achievable level of performance against which actual performance
can be compared.
Each of the six Professional Standards incorporates one of the characteristics of the profession
and provides direction to nurses about documentation.
Examples of How Nurses Meet the CRNBC Professional Standards:
Standard 1: Responsibility and Accountability: Maintains standards of nursing practice and
professional conduct determined by CRNBC and the practice setting.
Examples: Document all relevant data.
Ensure that each entry clearly identifies the nurse.
Be familiar with and use the documentation method used in the agency.
Advocate for agency policies and procedures that are clear and consistent with CRNBC
documentation standards.
Standard 2: Specialized Body of Knowledge: Bases practice on the best evidence and other
sciences and humanities.
Example:
Understand the purpose of and reasons for accurate and effective documentation.
Standard 3: Competent Application of Knowledge: Makes decisions about actual or potential
health problems and strengths, plans and performs interventions, and evaluates outcomes.
Examples: Document client assessments, interventions and the impact of interventions on client
outcomes according to agency policies and the CRNBC Standards of Practice.
Individualize care plans to meet the needs and wishes of individual clients.
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Standard 4: Code of Ethics: Adheres to the ethical standards of the nursing profession.
Examples: Be familiar with agency policies related to confidential information.
Safeguard the security of printed or electronically displayed or stored information.
Dispose of confidential information in a manner that preserves confidentiality (e.g., shredding).
Act as an advocate to protect and promote clients rights to confidentiality and access to
information.
Standard 5: Provision of Service in the Public Interest: Provides nursing services and
collaborates with other members of the health care team in providing health care services.
Examples: Use documentation to share knowledge about clients with other nurses and health
care professionals.Regularly update kardex information and ensure that relevant client care
information is captured in the permanent health record.
Keep the care plan clear, current and useful.
Standard 6: Self-Regulation: Assumes primary responsibility for maintaining competence and
fitness to practice.
Example: Keep current with changes in the documentation method used.
Practice Standard: Documentation
The CRNBC Practice StandardDocumentation sets out requirements related to documentation
and nurses practice. It also provides direction on how to apply the principles in the Standard to
practice.
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A G E N C Y P O L I C I E S A N D P R O C E D U R E S
Most health care agencies have documentation policies. These policies provide direction for
nurses to document the nursing care provided and the process of clinical decision-making in an
accurate and efficient manner. Agency policies include:
Description of the method of documentation; Expectations for the frequency of documentation; Processes for late entry recording; listing of acceptable abbreviations or the name of a reference text in which acceptable
abbreviations are found;
Acceptance and recording of verbal and telephone orders; and Storage, transmittal and retention of client information. Agency policies guide nurses in managing each of these specific situations. In situations
where policy changes are necessary, nurses advocate for the appropriate changes.
L E G A L P R I N C I P L E S
Legal standards for documentation have evolved over time and continue to evolve. Many are
based on Canadian common law court decisions as illustrated in the following examples:
Nurses notes are recognized as documentary evidence.
Case: Ares vs. Venner, 1970
Prior to 1970, nurses notes were not considered legal evidence admissible in court unless the
nurse was called to testify to the truth of the contents. In 1970, a new law was made in the Ares
vs. Venner case when, for the first time, nurses notes were recognized as admissible evidence.
Nurses notes were viewed as a record of the nursing care provided to the client. This case set
out the conditions in which nurses notes are now admissible (Richard,1995): nurses notes
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must be made contemporaneously; nurses notes must be made by someone having personal
knowledge of the matter then being recorded; and nurses notes must be made by someone
under a duty of care to make the entry or record.
Charting by exception can provide admissible evidence.
Cases: Kolesar vs. Jeffries, 1974; Ferguson vs. Hamilton, 1983; Wendon vs. Trikha, 1993
The health record is important both for what is recorded and for what is not recorded. In the
case of Kolesar vs.Jeffries (1974), the nurses notes were introduced as evidence and the
absence of entries permitted the inference that nothing was charted because nothing was
done. However, in a subsequent case, Ferguson vs. Hamilton (1983), the court rejected the
submission that the absence of any nurses entry is an indication of failure in care on the part of
the nurse(s). In this case, the court concluded that the fact that there was nothing in the nurses
notes during a period of time did not necessarily mean nothing was done, provided there was
evidence to the contrary and the usual practice was not to chart (Richard, 1995).
In the case of Wendon vs. Trikha (1993), the court concluded that omissions in documentation
will be interpreted against a nurse unless other credible evidence of nursing care demonstrates
that care was given. It means that if charting by exception is an agency policy, and if evidence
can be given that care was provided and noted according to this method, then this evidence will
be admissible and will provide proof of what was done (Richard, 1995). To meet legal
documentation standards, a system of charting by exception must include such supports such as
agency documentation policies, assessment norms, standards of care, individualized care plans
and flow sheets.
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Documentation Methods
Most methods of documentation fall into one of two categories: documentation by inclusion
and documentation by exception (Coleman, 1997). Documentation by inclusion is done on an
ongoing, regular basis and makes note of all assessment findings, nursing interventions and
client outcomes. Documentation by exception, on the other hand, makes note of negative
findings and is completed when assessment findings, nursing interventions or client outcomes
vary from the established assessment norms or standards of care existing within a particular
agency.
Charting by exception replaces the long held belief of if it was not charted, then it was not
done with a newpremise, all standards have been met with a normal or expected response
unless documented otherwise.
Documentation by exception is only appropriate when assessment norms or standards of care
are explicitly written and available within the agency. Documentation by exception is never
acceptable for medication administration.
The documentation method selected within an agency or practice setting needs to reflect client
care needs and the context of practice. Some agencies may combine elements of different
documentation methods and formats. If an agency decides to change its method or format of
documentation and/or expectations, it is important that this be done within a context of
appropriate planning and includes the involvement and education of nurses.
Regardless of the method used, nurses are responsible and accountable for documenting client
assessments, interventions carried out, and the impact of the interventions on client outcomes.
Clients who are very ill, considered high risk, or have complex health problems generally
require more comprehensive, in-depth and frequent documentation.
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Three common documentation methods - focus charting, SOAP/SOAPIER and narrative
documentation are described in the following sections. Any of these methods may be used to
document on an inclusion or exception basis.
F O C U S C H A R T I N G
With this method of documentation, the nurse identifies a focus based on client concerns or
behaviours determined during the assessment. For example, a focus could reflect:
A current client concern or behaviour, such as decreased urinary output.
A change in a clients condition or behavior, such as disorientation to time, place and person.
A significant event in the clients treatment, such as return from surgery.
In focus charting, the assessment of client status, the interventions carried out and the impact of
the interventions on client outcomes are organized under the headings of data, action and
response.
Data: Subjective and/or objective information that supports the stated focus or describes the
client status at the time of a significant event or intervention.
Action: Completed or planned nursing interventions based on the nurses assessment of the
clients status.
Response: Description of the impact of the interventions on client outcomes.
Flow sheets and checklists are frequently used as an adjunct to document routine and ongoing
assessments and observations such as personal care, vital signs, intake and output, etc.
Information recorded on flow sheets or checklists does not need to be repeated in the progress
notes.
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S O A P / S O A P I E ( R ) C H A R T I N G
SOAP/SOAPIER charting is a problem-oriented approach to documentation whereby the
nurse identifies and lists client problems; documentation then follows according to the
identified problems.
Documentation is generally organized according to the following headings:
S = subjective data (e.g., how does the client feel?)
O = objective data (e.g., results of the physical exam, relevant vital signs)
A = assessment (e.g., what is the clients status?)
P = plan (e.g., does the plan stay the same? is a change needed?)
I = intervention (e.g., what occurred? what did the nurse do?)
E = evaluation (e.g., what is the client outcome following the intervention?)
R = revision (e.g., what changes are needed to the care plan?)
Similar to focus charting, flow sheets and checklists are frequently used as an adjunct to
document routine and ongoing assessments and observations.
N A R R A T I V E C H A R T I N G
Narrative charting is a method in which nursing interventions and the impact of these
interventions on client outcomes are recorded in chronological order covering a specific time
frame. Data is recorded in the progress notes, often without an organizing framework. Narrative
charting may stand alone or it may be complemented by other tools, such as flow sheets and
checklists.
Use of Technology
Technology may be used to support client documentation in a number of ways. If technology is
used, the principles underlying documentation, access, storage, retrieval and transmittal of
information remain the same as for a traditional, paper-based system. These new ways of
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recording, delivering and receiving client information, however, pose significant challenges for
nurses, particularly with respect to confidentiality and security of client information. It is
important that nurses be supported by agencies in resolving these issues through clear policies
and guidelines and ongoing education.
E L E C T R O N I C D O C U M E N T A T I O N
A clients electronic health record is a collection of the personal health information of a single
individual, entered or accepted by health care providers, and stored electronically, under strict
security.
As with traditional or paper-based systems, documentation in electronic health records must be
comprehensive, accurate, timely, and clearly identify who provided what care (College of
Nurses of Ontario, 2002). Entries are made by the provider providing the care and not by other
staff. Entries made and stored in an electronic health record are considered a permanent part of
the record and may not be deleted. If corrections are required to the entry after the entry has
been stored, agency policies provide direction as to how this should occur.
Most agencies using electronic documentation have policies to support its use, including
policies for:
Correcting documentation errors or making late entries;
Preventing the deletion of information;
Identifying changes and updates to the record;
Protecting the confidentiality of client information;
Maintaining the security of the system (passwords, virus protection, encryption, firewalls);
Tracking unauthorized access to client information;
Processes for documenting in agencies using a mix of electronic and paper methods;
Backing-up client information; and
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Means of documentation in the event of a system failure.
Guidelines for nurses using electronic health records are as follows:
Never reveal or allow anyone else access to your personal identification number or password as
these are, infact, electronic signatures;
Inform your immediate supervisor if there is suspicion that an assigned personal identification
code is being used by someone else;
Change passwords at frequent and irregular intervals (as per agency policy);
Choose passwords that are not easily deciphered;
Log off when not using the system or when leaving the terminal;
Maintain confidentiality of all information, including all print copies of information;
Shred any discarded print information containing client identification;
Locate printers in secured areas away from public access;
Retrieve printed information immediately;
Protect client information displayed on monitors (e.g., use of screen saver, location of monitor,
use of privacy screens);
Use only systems with secured access to record client information; and
Only access client information which is required to provide nursing care for that client;
accessing client information for purposes other than providing nursing care is a breach of
confidentiality.
F A X T R A N S M I S S I O N
Facsimile (fax) transmission is a convenient and efficient method for communicating
information between health care providers. Protection of client confidentiality is the most
significant risk in fax transmission and special precautions are required when using this form of
technology.
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Guidelines for protecting client confidentiality when using fax technology to transmit
client information are as follows:
Locate fax machines in secured areas away from public access;
Check that the fax numbers and/or fax distribution lists stored in the machine of the sender
are correct prior to dialing;
Carefully check activity reports to confirm successful transmission;
Include cover sheet warnings indicating the information being transmitted is confidential; also
request verification that, in the event of a misdirected fax, it will be confidentially and
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;
Shred any discarded faxed information containing client identification; and
Advocate for secure and confidential fax transmittal systems and protocols.
Client information received or sent by fax is a form of client documentation and is stored
electronically or printed
In hard copy and placed in the clients health record. As the fax is an exact copy of original
documentation,
Additional notations may be made on the faxed copy as long as these meet the agency
standards for
Documentation and are appropriately dated and signed. Faxes are part of the clients permanent
record and, if relevant, can be subject to disclosure in legal proceedings. Faxed information is
written with this in mind.
If a physicians order is received by fax, nurses use whatever means necessary to confirm the
authenticity of the order.
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E L E C T R O N I C M A I L
The use of e-mail by health care organizations and health care professionals is becoming more
widespread as a result of its speed, reliability, convenience and low cost. Unfortunately the
factors that make the use of e-mail so advantageous also pose significant confidentiality,
security and legal risks.
E-mail can be likened to sending a postcard. It is not sealed, and may be read by anyone.
Because the security and confidentiality of e-mail cannot be guaranteed, it is not recommended
as a method for transmission of health information. Messages can easily be misdirected to or
intercepted by an unintended recipient. The information can then be read, forwarded and/or
printed. Although messages on a local computer can be deleted, they are never deleted from the
central server routing the message and can, in fact, be retrieved.
Having considered these risks and alternative ways to transmit health information, e-mail may
be the preferred option to meet client needs in some cases.
Guidelines for protecting client confidentiality when using e-mail to transmit client
information are as follows:
Obtain written consent from the client when transferring health information by e-mail;
Check that the e-mail address of the intended recipient(s) is correct prior to sending;
Transmit e-mail using special security software (e.g., encryption, user verification or secure
point-to-point connections);
Ensure transmission and receipt of e-mail is to a unique e-mail address;
Never reveal or allow anyone else access to your password for e-mail;
Include a confidentiality warning indicating that the information being sent is confidential and
that the message is only to be read by the intended recipient and must not be copied or
forwarded to anyone else;
Never forward an e-mail received about a client without the clients written consent;
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Maintain confidentiality of all information, including that reproduced in hard copy;
Locate printers in secured areas away from public access;
Retrieve printed information immediately; and
Advocate for secure and confidential e-mail systems and protocols.
From the nurses perspective, it is important to realize that e-mail messages are a form of client
documentation and are stored electronically or printed in hard copy and placed in the clients
health record. E-mails are part of the clients permanent record and, if relevant, can be subject
to disclosure in legal proceedings. E-mail messages are written with this in mind.
Similar to physicians orders received by fax, if physicians orders are received by e-mail,
nurses use whatever means necessary to confirm the authenticity of the orders.
T E L E N U R S I N G
Giving telephone advice is not a new role for nurses. What is new is the growing number of
people who want access to telephone help lines to assist their decision-making about how and
when to use health care services.
Agencies such as health units, hospitals and clinics increasingly use telephone advice as an
efficient, responsive and cost-effective way to help people care for themselves or access health
care services.
Nurses who provide telephone care are required to document the telephone interaction.
Documentation may occur in a written form (e.g., log book or client record form) or via
computer. Standardized protocols that guide the information obtained from the caller and the
advice given are useful in both providing and documenting telephone nursing care. When such
protocols exist, little additional documentation may be required.
Minimum documentation includes the following:
Date and time of the incoming call (including voice mail messages);
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Date and time of returning the call;
Name, telephone number and age of the caller, if relevant (when anonymity is important, this
information may be excluded); and reason for the call, assessment of the clients needs, signs
and symptoms described, specific protocol or decision tree used to manage the call (where
applicable), advice or information given, any referrals made,agreement on next steps for the
client and the required follow-up.
Telenursing is subject to the same principles of client confidentiality as all other types of
nursing care.
Common Questions about Documentation
What information is included in the progress notes?
Progress notes (nurses notes) are used to communicate nursing assessments, interventions
carried out, and the impact of these interventions on client outcomes. In addition, progress
notes are intended to include:
Client assessments prior to and following administration of PRN medications;
Information reported to a physician or other health care provider and, when appropriate, that
providers response;
All client teaching;
All discharge planning, including instructions given to the client and/or family and planned
community follow-up;
All pertinent data collected in the course of providing care, including data collected through
technology such as monitoring devices (e.g., strips produced during cardiac or fetal
monitoring); and
advocacy undertaken by the nurse on behalf of the client.
What is considered timely documentation?
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The timeliness of documentation will be dependent upon the client. When client acuity,
complexity and variability are high, documentation will be more frequent than when clients are
less acute, less complex and/or less variable.
Graphically, this is shown as follows:
Low
Med
High
Acuity
Complexity
Variability
Frequency of documentation
Who owns the health record?
The self-employed nurse or the agency in which the clients health record is compiled is the
legal owner of the record as a piece of physical or electronic property. The information in the
record, however, belongs to the client.
Clients have a right of access to their records and to protection of their privacy with respect to
the access, storage, retrieval and transmittal of the records. The rights of clients and obligations
of public agencies are outlined in the Freedom of Information and Privacy Act and are often
summarized in agency policies.
How does the Freedom of Information and Protection of Privacy Act (FOIPPA) affect
documentation?
The FOIPPA provides the legislative framework for information and privacy rights. This act
applies to all public bodies, including hospitals, health authority boards, CRNBC and similar
organizations. The legislation gives the public a right of access to records held by one of these
public bodies. Individuals have a right of access to personal information about themselves
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(including their health records) and a right to request correction of such information. The act
also prevents the unauthorized collection, use or disclosure of personal information by a public
body.
Is the information in the clients health record confidential?
Yes. Information in the health record is considered confidential. Client consent for disclosure
of this information to agency staff for purposes related to care and treatment is implied upon
admission, unless there is a specific exception established by law or agency policy. Client
consent is required if the contents of the health record are to be used for research or if any
client information is to be transmitted outside the agency.
Nursing documentation must be produced according to agency policy when:
Clients request access to their personal records;
CRNBC, under the Health Professions Act and Regulation needs to inspect or investigate
records; a subpoena is provided (e.g., negligence suit); or a statutory mandate requires the
release of the information (e.g., reporting communicable diseases or child abuse).
Do clients have access to their health record?
Yes. The CRNBC Standards of Practice require that nurses provide clients, in appropriate
circumstances, with access to their health records or assist them to obtain access to these
records. These standards are consistent with the Freedom of Information and Protection of
Privacy Act whereby clients can submit written requests for access to their records or for
information that might otherwise not normally be provided. Refer to agency policy as to the
process to follow when clients request access to their health records.
What happens to third party information when information in a health record is to be
released?
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Nurses may obtain relevant information about a client or an incident from another person, such
as the clients family member or friend. Nurses may also learn information about a third party
that is relevant to the client.
When a clients record has another persons name on it or contains information about another
person especially if the information was given in confidence - the record may need to be
severed before it is released. This means that some portions of the record are removed and
not released to the client requesting the record. For example, if the clients record included the
name of a friend of the client or another client, the section of the record that includes this
information would need to be removed before releasing the record to the client.
How is client information contained in communication books and shift reports
communicated?
Communication books and shift reports are used to alert the health care team to critical
information. These tools are used to direct others to the health record where the pertinent
information is recorded in detail. Relevant health information communicated by these tools is
documented in the health record (College of Nurses of Ontario, 2002).
Should I document incidents where calls are made because of a concern about a specific
client, but are not returned?
It is important to document only facts on client health records. In cases where calls are made
because of a concern about a specific client, a notation of these calls is made in the progress
(nurses) notes. A notation is made aftereach call, regardless of whether the call was returned.
If a call is returned, that is noted.
Under which circumstances are verbal orders appropriate?
Telephone orders
Orders accepted over the telephone are generally made without the physicians direct
assessment of the clients condition. Decisions are based solely on the nurses assessment of
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the client. Any miscommunication or lack of communication could lead to negative
implications for the client. Errors in recording telephone orders can also occur and there is
always the question of who made the error, the physician in ordering, or the nurse in recording.
Despite these concerns, there are times when telephone orders may be the best option for the
client .In these cases, the nurse makes himself/herself aware of the agencys policy with regard
to accepting and documenting telephone orders. Orders left on answering machines are not
acceptable.
Documenting Telephone Orders
Write down the time and date on the physicians order sheet.
Write down the order given by the physician.
Read the order back to the physician to ensure it is accurately recorded.
Record the physicians name on the physicians order sheet, state telephone order,
print your name, sign the entry and identify your status (e.g., RN).
On-site verbal orders
On-site verbal orders also have the potential for error and are avoided unless in an emergency
situation, such as a cardiac arrest. Nurses need to be aware of the agencys policy with regard
to accepting and documenting on-site verbal orders. Of nursing staff, only registered nurses
take verbal orders (and telephone orders) pertaining to medications.
Orders taken verbally and recorded by pharmacists
In B.C., pharmacists can accept and record verbal orders from physicians to dispense
medications. In these circumstances, nurses can carry out the orders from the label on the
dispensed medication.
Should chart pages or entries be recopied?
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Under no circumstances are chart pages or entries recopied. Errors are corrected according to
agency policy. If information is difficult to read, then add information in a note to chart or
note to file.
How are after the fact notes developed by nurses for potential use in the future handled?
There are occasions when nurses write notes after the fact (e.g., one day later, one week
later), most often to provide clarification following an incident or an unexpected client
outcome. Nurses usually write these notes while the event is current in the nurses memory, in
case of an investigation or lawsuit at a later date. It is recommended that nurses do not keep
these notes at home but provide them to a supervisor or risk manager within the agency for safe
keeping.
How long do health records need to be kept?
Self-employed nurses and agencies should have policies on the retention of health records and
client documentation. Current legislation needs to be considered in the development of these
policies. Legislation differs, depending upon the setting. In all settings, records that contain
references to blood or blood products must be maintained in perpetuity (MOH communication,
1996/1997). In other words, these records must be kept forever.
In acute care hospitals, documents contained in the health record may be considered primary,
secondary or transitory. Records are kept for the following time periods (from date of
discharge):
Primary documents (e.g., physicians orders, nursing admission assessment, consultations,
discharge summary, and notice of death) - 10 years
Secondary documents (e.g., most diagnostic reports, medication records, flow sheets and
nurses notes) six years
Transitory documents (e.g., diet report, graphic chart) - one year
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Depending upon agency policy, records of minors may be required to be kept longer than the
time periods listed above.
In community care, public health and mental health settings, client records of adults are
generally kept for 10 years and minors for 25 years from the date of service.
Some exceptions apply to the timeframes listed above, requiring certain practice settings to
have longer retention periods (e.g., forensic mental health). Nurses need to be aware of agency
policy and legislation impacting these retention periods.
What records are self-employed nurses required to keep?
Self-employed nurses must have a documentation system. What is recorded will depend on the
type of service offered. Forms can be simple and still address nursing assessment, plans,
interventions and client outcomes. The CRNBC Practice Standard Self-Employed Nurse
(pub.413) provides direction on documentation requirements for self-employed nurses and is
available from the CRNBC website.
Bibliography
Ares vs. Venner. 14 D.L.R. (3rd) 4, reversing 70 W.W.R. 96, (S.C.C.) 107, 112, 114, 115, 117,
120, 127 (1970).
B.C. Health Care Risk Management Society (2002). Guidelines to Section 51 of the Evidence
Act. Victoria: Author.
Canadas Health Informatics Association. (2001). Guidelines for the protection of health
information. Toronto:Author. Coleman, A. (1997). Where do I stand? Legal implications of
telephone triage. Journal of Clinical Nursing, 6, 227-231.
College of Nurses of Ontario. (2002). Nursing documentation standards. Toronto: Author.
(PAM: Charting) Ferguson vs. Hamilton Civic Hospital. 144 D.L.R. (3rd ed.) 214 (1983).
Kolestar vs. Jeffries. 59 D.L.R. (3rd ed.) 367 (1974)
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C