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