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 Generation

Documentation norms relate to professionalism and accountability and are based on sound clinical documentation principles. Our expectations of one another, and the digital behaviours that express those expectations, promote good documentation practices in the six distinct CIS activities listed below:

• Medication Documentation

• Adverse Reaction Documentation

• Health Problem Documentation

• Diagnosis Documentation

• Clinical Documentation

  • Summative Documentation

  • Change Documentation

  • Copy-Paste

  • Shared Documents

• Encounter Documentation

• Required Documentation

More information, and practical do's and don'ts, appear in:

• • Norms: Documentation (Prescribers)

  • Guide: Clinical Copy-Paste

  • Crib-Sheet: Abbreviations Do-Not-Use List

Document Signing 

Clinical documentation can be a building block or a composite documentation object. Building blocks include things like problem lists, medication lists, patient coordination notes and hospital course notes. These are usually multi-authored and "reviewed" or "updated" as edits are made by one or more member of the health team. 

Composite objects are usually referred to as "Notes" in Connect Care. These can be progress notes as well as summative notes (e.g., consult, history & physical, discharge summary, exceptional care plan, etc.). Notes can also be incorporated into "Letters" as part of communication workflows. Some summative notes are automatically shared with external information systems, such as Netcare (see Shared Documents). In most cases, accountability rests with a specific provider. The provider can "Pend", "Share" or "Sign" the note.

Pending, Sharing or Signing

• "Pending” a note saves its current state as a draft but does not trigger any automated distributions to external systems. The author can return at any time to complete the note. Other authorized prescribers (e.g., attending physician) can take over a pended note by opening it for “Editing”. Pended notes appear within the “Incomplete” tab of the Notes activity within an opened chart.

• "Sharing” a note saves the current state as a draft and does not trigger any automated distributions. The author, and other members of the clinical team (e.g., other trainees), all have access and can continue to work on the note. Authorized prescribers (e.g., attendings) can also take over a shared note by opening it for “Edit”. This workflow allows teams to collaborate in the preparation of summative documents, like discharge summaries.

• "Signing" a note saves and locks the current state of its content. Signing also triggers relevant automated tasks, such as meeting criteria for closing an encounter or distribution to external systems. A signed note cannot be changed unless it is "Addended" by an authorized provider. The author can re-open the note for "Editing", requiring a re-sign to re-close the note.

Pended and shared notes are not available for viewing outside Connect Care, or the current Connect Care patient encounter. Once an authorized prescriber signs a pended or shared note, it becomes finalized, is visible on the appropriate Notes activity tab, and automated distribution actions (e.g., primary care provider copy, Netcare copy) are triggered. Any manual routing should be saved until after the note is signed.

• Tip: Pend, Share or Sign?

Co-Signing, Attesting or Addending

An accountable provider for a note may not be the original author of the note. Accordingly, concepts like "co-signing", "attesting" and "addending" are important to distinguish. These are commonplace when trainees participate in care documentation.

• "Cosigning" allows an accountable (usually supervising) provider to validate a note without changing its content or adding commentary.

• "Attesting" allows a supervising prescriber to validate a trainee note while also adding commentary that is displayed at the top of the note when displayed in Connect Care or external information systems.

• "Addending" a note allows an accountable provider to open and "take over" a note so that its original content can be edited. No attestation commentary is added. The author name changes to the addending authorized provider and the note audit history reflects all changes to content and authorship.

Expectations for cosigning or attesting are specified in trainee programs. Some trainees may not be able to complete a note without indicating the identity of the provider expected to co-sign, attest or addend.

• Manual: Trainee Accountabilities

Document Corrections

Correction of the content of clinical documentation may be appropriate after an encounter has been closed. This is possible using "Addendum" or "Edit" options that appear on right-click when a note is viewed in the Chart Review activity. All changes to the note are audited, recorded and available for review. The change record includes the identity of the person who made the changes, and the date and time when they were performed.  Changes made for quality, safety or chart correction purposes -- outside of the original care encounter -- may merit use of the chart access documentation workflow.

• Manual: Chart Access

• Tip: Documenting Chart Access

More Information

The above resources focus on documentation responsibilities common to prescribers (physicians, trainees, midwives, clinical associates, etc.). Parallel considerations apply to nursing and allied health professions:

• Norms: Documentation (Nursing and Allied Health)

Norms resonate with but do not replace any organizational policies or required procedures that may pertain in AHS or any of its affiliated organizations.

• Policy: Clinical Documentation