NOTICE WITH RESPECT TO SIGNING PROGRESS NOTES WRITTEN BY STUDENTS, NURSING EXTERNS AND CANDIDATES A legal opinion Hélène d Anjou Lawyer Department of Legal Services, OIIQ in collaboration with Jacinthe Normand Director-consultant Department of External Affairs, OIIQ Translator s notes: This text is a translation of a legal opinion entitled AVIS CONCERNANT LA SIGNATURE DES NOTES D'ÉVOLUTION RÉDIGÉES PAR LES ÉTUDIANTES, LES EXTERNES ET LES CANDIDATES (18 mai 2005), translated with the permission of the Ordre des infirmières et infirmiers du Québec (OIIQ). Readers should consult the original French document for the official text if needed. The feminine article ( she, her ) refers to both the masculine and the feminine throughout this document except in quotations from the Quebec Civil Code, in which case the masculine he or his refers to both sexes. To help in the understanding of this document, the term progress notes, and its shorter version, notes, are consistently presented in italics throughout this translation. These italics were not used in the original French version. Finally, an effort has been made to make this translation as understandable as possible by anglophone nurses and nursing students, while staying as close as possible to the original version. To this end, words have sometimes been added to clarify the text and, in particular, the terms usager, client, patient have all been translated as patient throughout the text to facilitate comprehension in English. Translator: Patrick Bolland pbolland@tradscium.com 1
With the development of the statutes of nursing extern ( extern ) and candidate to the profession of nursing ( candidate ) and of the regulations authorizing externs and candidates to perform nursing activities, a number of questions have been raised about the obligation for nurses monitoring students, externs and candidates in the clinical setting, to countersign the progress notes in patients files when the notes are written by students, externs and candidates. The present opinion aims at clarifying this issue. The purpose and importance of progress notes From both a clinical and professional perspective, the documentation concerning the nursing care a patient receives refers to all the information relative to the nursing care that is recorded in the patient s file, as well as to the activity of writing down this information. 1 Whether it takes the form of progress notes, a therapeutic nursing plan or an evaluation form, such a written report is central to the quality of care patients receive and constitutes an essential activity in the practice of nursing. In the context of providing nursing care, the notes in the patient s file are more often referred to as "progress notes". Indeed, this term provides a good description that the information noted in the patient s file reflects the changes over time in the client's health status. 2 The progress notes written by the nurse, student, extern or candidate, which are consigned to the patient s file, all have the same clinical objectives. These objectives are the following: to put in writing the relevant data on the evaluation of the patient s physical and mental health state; to note the significant parameters obtained from monitoring the patient and also to provide the interpretation of these data; to record the results of care provided and of treatments received, including those measured with the help of different evaluation instruments; to describe events related to the health situation of the patient; to explain the nurse's therapeutic decisions; to describe the interventions and adjustments in care that are made, if need be; to record the patient s reactions and the results obtained following the care and treatments received. Progress notes also make communication easier within the nursing and interdisciplinary teams, thereby contributing to the continuity of care to the patient. In the legal context, the courts have on a number of occasions insisted on the importance for nurses of writing adequate and complete progress notes, which, particularly, enable doctors to make an enlightened decision with respect to the treatment to prescribe. The courts have also underlined the importance for the doctor to consult the notes written by the nurse, the lack of such consultation potentially engaging the doctor s civil responsibility. 3 1 OIIQ (l Ordre des infirmières et des infirmiers du Québec) : Énoncé de principe sur la documentation en soins infirmiers, 2002. 2 2. Ibid, page 2. 3 Bérubé vs. Hôpital Hôtel-Dieu de Lévis (2000) RRA 484 (C.S.); Stunnel vs. Pellet ier (1999) RJ.Q. 2863 (C.S.); St- Jean vs. Mercier (1999) RJ.Q.1658 (CA); Claveau vs. Guimond (1998) RRA 613 (CA); Cloutier vs. Hôpital Le Centre hospitalier de l'université Laval (1990), RJ.Q. 717 (CA); Rizzo vs. Hôpital Notre- Dame (1975) C.S. 425. 2
It should be emphasized that the patient s health file is a legal document 4 and that the nurse's progress notes have, for many years, been recognized by the courts as providing in themselves proof of the information they contain. 5 These notes testify to the care that has been provided and serve to re-establish the facts in the eventuality of a health-provider facing charges in a court of law. Rules about signing progress notes The nurse, student, extern or candidate is required to write progress notes and sign them, in conformity with the rules and regulations relevant to this activity and to the policies and directives of the institution in which care is provided. One of these rules is that the progress notes be written by the person who has personal knowledge of the facts that are recorded. In her notes, the nurse reports her interventions and the relevant data about the patient, as she has herself observed them, and not as they have been noted or reported by someone else. Since the health-care recipient's file can constitute an important element of evidence in case of litigation, it is important that these notes correspond to the care-provider s own observations or interventions, whether she is a nurse, student, extern or candidate. Hospital files, including the nurses' notes, written each day by a person who has personal knowledge of the facts and whose work consists in writing these down or writing them in the files, must be received as prima facie proof of the facts they describe. 6 The progress notes written by the student, extern or candidate have the same legal status as those written by a nurse. Regardless of the level of supervision that she receives (formal supervision, control, twinning, mentoring, etc.), the student, extern or candidate assumes personal responsibility for her interventions in the clinical setting, including the writing of progress notes. When she records her observations, she is participating in the provision of services offered by the institution and performing her professional activities. It sometimes happens that the writing of observation notes constitutes part of clinical training and that it may be supervised by a nurse. In this case, the nurse or teacher who supervises the student during her training period and the nurse with whom the extern is paired for exercising nursing activities may, when requested to do so or on her own initiative, give instructions to the student or extern on how to write the observation notes, when the student, extern or candidate is faced with a particular situation. In some cases, the nurse may even verify the notes written by the student, extern or candidate and ask her to make corrections. However, and regardless of the degree of supervision, control or monitoring of the work of the "novice", the nurse never acts in the name of the student, extern or candidate in the writing of her notes. 4 In health-care institutions, the file is a clinical tool, defined according to regulations about what it must contain, as well as the confidentiality of the information it contains: Loi sur les services de santé et les services sociaux (L.RQ., c. S4.2), art. 17 et seq.; Règlement sur l'organisation et l'administration des établissements (0.1320-84, 1984 116 G.O.II 2745 and subsequent modifications, art. 50 et seq.) 5 5. Arès vs. Venner (1970) RC.S. 608. 6 (This text has been translated from the French for this document) Ibid., p.626. The importance attributed to proof obtained from information in the patient s file has been emphasized by the courts on several occasions, for instance a recent judgment: Reinhart c. Hajj, C.S. 500-05-002961-959 (31.01.05). The original French text reads: Les dossiers d'hôpitaux, y compris les notes des infirmières, rédigés au jour le jour par quelqu'un qui a une connaissance personnelle des faits et dont le travail consiste à faire les écritures ou à rédiger les dossiers, doivent être reçus en preuve prima facie des faits qu'ils relatent. 3
Given the above, the nurse is in no way obliged to countersign the notes of the student, extern or candidate. If the nurse or teacher chooses to add her signature under the notes written by the student, extern or candidate, she is then committed to their content and is endorsing what has been written, including any interventions that she was not in a position to witness. The fact of putting one's signature below a written document signifies that one endorses the statements that are made in the document: Signing a written document is the most evident expression that a party has consented to the juridical act that it describes. 7 The nurse who assumes the supervision of the student, extern or candidate signs the notes that reflect her own interventions and observations. It is only appropriate for the nurse to sign the notes with the student, extern or candidate when she has herself participated in the observations or has herself intervened in the care or treatment of the patient described in the written report. The nurse s responsibility consists in ensuring the appropriate degree of supervision and in giving adequate instructions and advice. As for the nurse who is responsible for providing care to the patient, the fact that a student, an extern or a candidate intervenes with the patient and writes progress notes that correspond to her own interventions and observations in no way exempts her from her own responsibility with respect to controlling the care provided to the patient, nor the requirement to write her own progress notes with respect to this. Her responsibility consists in deciding the care required and in ensuring that the patient receives it. The verification of progress notes written by the student is part of this responsibility, to the extent that it allows the nurse to ascertain that the patient has in fact received the required care. If the nurse encounters an anomaly when reading these notes, she is required to take the required corrective measures. Reference to the supervision exercised by the nurse with respect to the progress notes is an administrative measure. The nurse is not required to mention in the patient s file that she has controlled and verified the work of the student, including her progress notes. The health file is a clinical instrument concerning the patient. Rather, the nurse should consign any such information to a separate file, such as a register identified by the name of the student, extern or candidate. Signing the progress notes by a student, an extern or a candidate The legal meaning of a "signature", as defined in the Quebec Civil Code 8, is sufficiently broad to include, on the one hand, the writing of one's full name, and, on the other, writing one's initials, to the extent that these allow for the clear identification of the person who writes them and that this person currently uses these initials. A signature is the affixing by a person, to a writing, of his name or the distinctive mark which he regularly uses to signify his intention. 9 7 J.-C. Royer, La preuve civile, 2 è édition, Éditions Yvon Blais, 1995, page 187. In French, the text reads: "La signature d'un écrit est l'expression la plus évidente qu'une partie a consenti à l'acte juridique qu'il constate". 8 Laws of Quebec, 1991, c. 64. 9 Quebec Civil Code, 1991, updated 2004, chapter 64, 2827. 4
Given these principles and given the objectives mentioned above with respect to progress notes, it is important that the signing of the notes permits the clear identification of the professional who writes these notes as well as the capacity in which she signs it, in order particularly that those who intervene in providing care can refer to them for purposes of follow-up, if need be. In this context, in order for the initials to be a valid substitute for signing progress notes and allow for the identification of the nurse who signs them, we encourage the nurse to write the initial of her first name followed by her family name written out in full, then her occupational title. However, the initials of the first name and family name can be used to the extent that the complete name appears close to the initials (for example at the bottom of the page) or in information that is stored permanently in the patient s file. As for the nursing extern, article 7 of the Règlement sur les actes professionnels qui, suivant certaines conditions et modalités, peuvent être posés par une externe en soins infirmiers 10 (which could be translated as Regulation of the professional acts which, under certain conditions and modalities, can be performed by a nursing extern ) specifies how the nursing extern is required to record her interventions: The nursing extern reports her intervention in the patient s file by writing her signature, accompanied by the abbreviation: "Ext. Soins inf." (extern), "Ét.sc.inf." (student), and CPN (candidate). As for the nursing student and candidate to the profession of nursing, there is no prescribed standard identifying how she should sign her progress notes. In line with the principle mentioned above, we recommend that the nursing student and candidate report their interventions by signing them with their signature, accompanied by the abbreviations "Ét. soins inf." (nursing student at the Cégep level) "Ét. sc.inf." (nursing student at the university level), and CPN (candidate to the profession of nursing). 10 R.R.Q. c. 1-8, r. 0.2. 5