Long-Term Care Newsletter
Nursing Notes: Key Considerations for Long-Term Care Facilities
Nursing notes are a vital tool in long-term care facilities. They support ongoing care by documenting a resident’s medical history and observations made by or interactions with the various members of a resident’s care team. In this newsletter, we explore some of the important considerations for long-term care facilities with respect to nursing notes.
What are nursing notes?
Nursing notes, as we tend to call them in long-term care facilities, are the record of communications among members of the nursing care team (such as the RNs, LPNs, CCAs and others) regarding a resident’s health history, care plans, injuries, illnesses, response to treatment and more. In long-term care, the notes also include observations about a resident’s condition or whereabouts throughout the day. Nursing notes are an important tool for providing excellent and consistent care to residents.
The introduction of electronic communications has expanded the variety of nursing notes. Nursing notes include both paper and electronic documentation, charts, care plans, test or physical exam results, verbal, telephone and written orders, progress or observational notes, photographs, videos, and documentation from telephone or in-person conversations, among others. Any documented interaction related to a resident’s care is part of the record.
Importantly, nursing notes are also legal documents. They can be admitted as evidence in a legal proceeding if questions arise about the care provided. The Supreme Court of Canada (“SCC”) addressed nurses’ notes in a case called Ares v Venner,  SCR 608 (SCC). That case involved nurses’ notes in a hospital, but the principles apply in long-term care facilities too. The SCC acknowledged that nurses’ notes are, by their nature, accurate and thorough as they are prepared for the purpose of making medical and/or care decisions. Given that accuracy and thoroughness, the SCC ruled that legal adjudicators could accept nurses’ notes as evidence of what is written in them. For instance, if nursing notes indicate that a resident had bruising, an adjudicator can accept that statement as evidence that the resident did indeed have a bruise. There would be no need to call the medical professional as a witness in the legal hearing to testify to that fact. If another party in a legal proceeding disagrees with what is written in the nursing notes, they could call a witness to lead evidence of any inaccuracy. The SCC explained:
Hospital records, including nurses’ notes, made contemporaneously by someone having personal knowledge of the matters then being recorded and under a duty to make the entry or record should be received in evidence as prima facie proof of the facts stated therein. This should, in no way, preclude a party wishing to challenge the accuracy of the records or entries from doing so. Had the respondent here wanted to challenge the accuracy of the nurses’ notes, the nurses were present in court and available to be called as witnesses if the respondent had so wished.
What standards are expected in keeping nursing notes?
Generally, nursing notes are to be made at or about the time that staff deal with the resident.
The law does not require that nursing notes be perfect. At para. 62 in Brito (Guardian ad litem of) v Woolley, 2005 BCSC 443, the British Columbia Supreme Court stated:
The law does not impose a standard of perfection on medical personnel in their preparation and maintenance of medical records. Rather, it is a reasonable standard of care, given the experience of the medical personnel and the context in which the medical records were prepared. Occasional inconsistencies, inaccuracies, and/or omissions are tolerated.
Nursing notes can be corrected or amended, but only where:
- The correction or amendment is routine in nature, such as a change in name or contact information;
- To ensure the accuracy of the information documented; or
- At the request of a patient identifying incomplete or inaccurate information.
If it is necessary to correct or amend nursing notes, there are protocols. The person making the correction or amendment should identify themselves, specify the date and time of the correction and sign or initial the change. Correct and incorrect information should be demarcated, such as by using bold or strikethrough text. If incorrect information is removed from the record it should not be destroyed but, instead, preserved so that the information can be traced and is readily accessible if a review or audit is necessary.
Specifying the date and time of corrections and amendments is critical. Corrections or amendments made after learning of a legal action or the potential for an action could be a real problem as they may undermine the custodian or individual’s credibility and defence.
Where possible, the corrections or amendments should be made by the individual who made the record in the first place.
Sometimes, people think later of something they should have put in nursing notes. A “late entry” can be made but should be made as soon as reasonably possible. It is important to specify the date of and time of a late entry, along with signing or initialling it.
Who is responsible for retaining nursing notes?
The party with custody of the nursing notes, whether in paper or electronic format, is responsible for ensuring the notes are retained and stored according to legal and regulatory requirements. Long-term care facilities such as nursing homes are the custodians of the nursing notes made by their staff.
What are the legal requirements for those who retain or create medical records?
Nova Scotia’s Personal Health Information Act (“PHIA”) establishes legal requirements for custodians of personal health information when the information is collected for the purposes of providing health care or the planning and management of the health system. PHIA recognizes both the right of individuals to protect the privacy of their personal health information and the need of custodians to collect, use and disclose personal health information for the effective provision, support and management of health care. PHIA sets out rules allowing individuals access to their personal health information and to ask for corrections if it contains errors or is out of date.
Individuals who create or diarise medical records/nursing notes have legal obligations established by regulatory authorities and the common law. Medical professionals such as physicians, nurses, physiotherapists and occupational therapists are governed by regulatory bodies that establish codes of conduct and professional standards for their members. Generally speaking, these bodies mandate that medical records should be factually accurate and legible.
Nursing notes are a fundamental tool to ensure excellent and consistent care to residents in nursing homes. They are also legal documents; in fact, they can be accepted in a legal hearing as truth of what is written in them.
Further, under the PHIA, the long-term care facility is the custodian of those notes.
Given the important status of nursing notes and legislated obligations in respect of them, it is crucial that long-term care facilities understand the obligations on them and their staff/service providers and take all steps to ensure that they are in compliance.
This newsletter is produced by the Long-Term Care Law Group at Wickwire Holm to keep our clients and friends informed of developments in the law and emerging issues. It is intended for general information purposes only. In preparing and circulating this newsletter, Wickwire Holm is not providing legal or other professional advice. We invite you to reach out to us if you have questions about any issues raised within this newsletter. Contact us at firstname.lastname@example.org or (902) 429-4111.