Documentation Norms

The Connect Care clinical information system (CIS) serves all who provide care where Connect Care is the record of care. Documentation Norms are about how Connect Care users collectively improve the benefit-to-burden balance of documentation work.

Documentation Norms relate to professionalism and accountability and are based on sound clinical documentation principles. Our expectations of one another, and the digital behaviors that express those expectations, promote good documentation practices in the 6 distinct CIS activities listed below. More information, and practical do's and don'ts appear in:

Bottom Line

Health Problem Documentation

The Connect Care CIS list of active health conditions (“Problem List”) appears in all charts in all contexts. It lists diseases, disorders, injuries and health conditions that have an impact on, or could be impacted by, a patient’s current care. For a medical condition to be added to the Problem List, it should be persistent, clinically relevant and specific. Inactive or past problems can be listed elsewhere in the chart, usually as part of the patient’s medical or surgical history.

Health problems identified in the Problem List are standardized labels for conditions, diagnoses or risks. They determine which ordering tools, documentation aids, coordination aids, decision supports, patient resources and professional billing prompts are offered to speed workflows.

All Prescribers share responsibility to update and manage Health Problems, especially those they have entered themselves. Problem List reconciliation (resolve, revise or promote) occurs at first encounter, care transitions, or appropriate intervals.

Diagnosis Documentation

Health encounters occur for a reason. Diagnosis documentation is about how responsible Prescribers indicate the most responsible reason for the health encounter or the conclusion reached as a result of the encounter.

Encounter diagnoses may impact follow-up actions, after-visit summaries, enrolment in clinical investigations, inclusion in patient registries, content of analytics reports or initiation of chronic disease management plans.

Prescribers are responsible for the selection and recording one primary visit diagnosis (outpatient) or most responsible diagnosis (inpatient). This can be promoted from the Problem List as part of problem list reconciliation.

Medication Documentation

Medication documentation is about how medication decisions are recorded, communicated, validated, implemented, supported and followed. It promotes safe, effective and appropriate drug therapy as part of patient-centred care. The Medication List is a record of medications in active use by a given patient at a given time.

Ongoing maintenance and periodic review of a comprehensive medication list is essential for clinical decision support, medication administration, adverse reaction surveillance, patient education, patient adherence and system-to-system health record transfers.

The collection of the best possible medication history occurs in both outpatient and inpatient workflows. Reconciliation of prior with new medications occurs at care transitions (e.g., admission, discharge, transfer) as well as periodically during ongoing disease management.

Good practice is reflected by clear documentation of any variance between intended and actual medication use and any reasons for change from prior to temporary or ongoing new medication lists.

Adverse Reaction Documentation

Ensuring documentation of a patient’s adverse reactions to medication, immunization, dietary, supplement and environmental exposures is a minimum use expectation. Managing this documentation involves validating prior reactions, characterizing current reactions and removing disproven reactions.

Consistent use of standardized descriptors ensures that decision supports (e.g., alerts, reminders) have few false positives and negatives.

Entering, editing and reviewing adverse reactions is done in the “allergy/contraindications” activity which can be accessed through the Patient Storyboard in all CIS contexts. Serious adverse drug reactions must be supplemented with an Adverse Drug Reaction Report when first documented.

Clinical Documentation

Clinical documentation is the process by which we record health observations, assessments or plans so that they can be shared with other members of the health care team. All forms of clinical documentation serve communication, collaboration and coordination.

There are two categories of clinical documentation:

  • Summative documentation gathers all information pertinent to an encounter or episode, organizes observations, exposes meaning, and offers a plan keyed to care goals. Examples of summative documents include consultation notes, admission histories, discharge summaries, surgery reports, transfer notes and integrative plans of care.
  • Progress documentation records new or changed findings, clinical progress or otherwise indicates what is unique or important about a defined period within a larger care encounter or episode. Progress notes are typical transactional documents. Ideally, they highlight clinically important developments since the last summative note.

Good clinical documentation is concise and unique. A well-organized electronic record allows brevity because related information can be referenced and linked. Clinical notes can be interpretive, focusing on the meaning of data organized in appropriate sections of the record.

In general, copy-paste is not needed and should not be used. It is always better to reference original content and highlight changes occurring since. Any copy-out (copy from Connect Care CIS to a separate information system) must be done with extreme caution, as there is risk of a privacy breach. CIS users who copy-paste for convenience (e.g., as a template for the next note) should verify that all copied information remains correct, pertinent and relevant. The origin of copied information must be attributed, acknowledging the original context in which the copied information was generated.

Encounter Documentation

Clinical encounters occur in both inpatient and outpatient settings and are reflected in the Connect Care CIS as a package of information related to a specific visit, admission or intervention. ‘Opening’ and ‘Closing’ these encounters affects the encounter properties which, in turn, affects what other Connect Care users can see or do.

The health care Prescriber designated as the responsible Prescriber for an encounter is accountable for signing encounter content and closing the encounter event.