165. CCA Study Notes: Client Records and Documentation for Support Workers

The Big Picture

A client record keeps important information about a client’s condition, care, treatment, and response to care. A chart, also called a record, is a permanent legal document that follows the client from admission through discharge or death.

Documentation helps health care team members communicate, plan care, follow changes, and keep information current. It also creates a legal record of what workers observed, did, and recorded.

For support workers, documentation duties depend on the care setting and employer policy. Community and home care workers are required to document the care they provide. Facility policies determine whether support workers document care there.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

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Course Notes: Key Ideas You Need to Know

What Is a Client Record or Chart?

A chart is another name for a client record. It is a permanent legal document containing information about the client’s condition, signs and symptoms of illness, care and treatment, and responses to care.

The record covers the period from admission until discharge or death. Health care providers also use it as a reference for future treatment.

A court order called a subpoena might require the record during a malpractice ⓘ case. In Ontario, the information provided states that records are kept for a minimum of 5 years.

Signs, Symptoms, and Observation

These terms describe different types of information about a client.

Term	Meaning
signs	Information about a client’s health gained through observation and the senses. Signs are also called objective data.
symptoms	Information the client reports that other people do not directly observe. Symptoms are also called subjective data.
observation	The active use of the senses to gather information about the client’s current condition.

Keeping signs and symptoms separate helps you understand where recorded information came from.

Why Client Records Are Used

Client records serve several purposes for the health care team.

• Communication: All health care team members must be informed about the client’s condition and care during each shift. Reports and recording help the team share this information accurately. The care plan is one part of the report.
• Planning care: Records show how the client responded to procedures or care. The health care team uses this information when planning future interventions.
• Keeping information current: Client needs, preferences, conditions, care plans, laboratory reports, and doctors’ orders change. Records keep current information available.
• Accountability: Printed charts are signed and dated, while computerized charts track entries electronically. Keep track of printed charts and emails. Team members are accountable for their own words and actions. In a legal case, you might need to testify about what you wrote. Computer reports are traceable through your log-in and are legally binding ⓘ.
• Continuity of care: Written records preserve information about past health issues and treatments. This helps health care providers recognize patterns and changes even when team members change.
• Quality assurance: All care and interventions must be documented. This helps support best practices, an individualized care plan, and consistent care.
• Education and research: Client observations and responses to treatment provide information for future interventions and scholarly research.
• Funding: Client acuity, meaning severity of illness, is linked with decisions about staffing and equipment needs.

Common Documents Found in Client Charts

Charts differ between employers because facilities and agencies use different systems and forms.

Documents Used to Plan and Organize Care

Document	What It Records
Data forms	Physical, emotional, social, and cognitive health information for long-term care clients. They also include activities, interests, medications, treatments, and therapies.
Assessment forms	Health issues and needs recorded by nurses and case managers.
Home assessment forms	Changes needed in the client’s home during rehabilitation.
Care plans	Goals and interventions based on the assessment.

Documents Used to Record Ongoing Care and Observations

Document	What It Records
Progress notes	Care provided, the client’s response, observations, activities, special treatments, medications, date, time, and initials.
Graphic sheets	Measurements and observations from every shift or three to four times each day.
ADL checklists and flow sheets	Actions related to hygiene, food and fluids, elimination, rest, sleep, mobility, activity, and social interactions.
Task sheets	Care and services provided in community settings.
Other flow sheets	Frequent measurements and observations, including some recorded every 15 minutes or more often.

Documents Used for Summaries, Events, and Quick Reference

Document	What It Records
Summary reports	Care and services over a period of time.
Incident reports	Written accounts after an accident, error, or unexpected event.
Kardex	A quick summary of current information from the chart.

Assessment Forms

An assessment is an evaluation of information collected about the client through observation, reflection, and communication. It is part of the care-planning process.

Nurses and case managers use assessment forms to record health issues and needs. They draw information from data forms and other sources, including observations from health care team members.

Care Plans and Interventions

A care plan states the care and services the client must receive. It contains goals and interventions based on the assessment.

An intervention is an action or measure taken by the health care team to help the client meet a care-plan goal.

Sometimes the assessment and care plan appear on the same form.

Progress Notes

Progress notes are also called narrative notes. They record:

• care given
• the client’s response to care
• observations
• activities
• special treatments
• medications
• date, time, and initials

Different health disciplines ⓘ sometimes share one set of progress notes. Other workplaces separate notes by discipline.

Employer policy determines whether a support worker records information in progress notes.

Graphic Sheets

Graphic sheets record measurements and observations every shift or three to four times per day.

Information might include:

• blood pressure
• temperature
• pulse
• respirations
• height
• weight
• intake and output
• routine care
• bowel movements
• physician or nurse practitioner visits

ADL Checklists and Flow Sheets

Activities-of-daily-living, or ADL, checklists record care related to daily activities.

An ADL checklist, sometimes called a tick sheet, uses check marks in boxes. An ADL flow sheet uses codes.

For example:

• I means independent.
• A means assist.

Both forms provide little or no space for detailed writing.

Task Sheets

Some community employers use task sheets to record care and services.

The form has boxes for each day and areas for different care or support activities. The worker checks the appropriate box after providing the service.

Other Flow Sheets

Some flow sheets track frequent measurements and observations.

Examples include:

• blood pressure
• pulse
• respirations
• intake and output

Some measurements appear every 15 minutes or more often. These flow sheets help monitor clients with serious illnesses.

Summary Reports

Summary reports cover care and services over a period of time.

Community settings and some long-term care facilities use them to summarize the client’s condition:

• monthly
• every second month
• every third month

Incident Reports

Incident reports provide a written account after:

• an accident
• an error
• an unexpected event

Community settings commonly call these occurrence reports.

Kardex

A Kardex is a card file that summarizes information from the chart.

It usually includes:

• current diagnosis
• medications
• treatments
• special equipment needs
• routine care measures

Workers use it as a quick source of current information. Staff update it as information changes.

Some facilities use the Kardex system. Community settings rarely use it.

What Documentation Means

Documentation, also called charting, records the care a health care worker gave and the observations and basic assessments made during care.

Documentation is a legal requirement for health care providers.

Support workers in community or home care settings are required to document their care. In facilities, employer policy determines whether support workers document care.

Employer policies also control:

• when workers record
• how often they record
• what they record
• who records
• approved abbreviations
• ink colour for written records
• correction procedures

Four Things to Focus On When Recording

Record:

1. What you observed, including symptoms the client reported.
2. What you did.
3. When you did it.
4. How the client responded.

These four points keep the entry focused on care and the client’s response.

Written and Electronic Documentation

Both written and electronic records have strengths and limitations.

Written Reports	Electronic Reports
Provide a permanent record.	Provide fast and efficient recording.
Take more time to complete.	Create added confidentiality concerns if unauthorized people gain access.
Poor handwriting makes entries difficult to read.	Require secure use of computer systems and electronic devices.

Hospitals, long-term care facilities, and community agencies increasingly use electronic charting.

Some facilities place computers outside client rooms. Support workers enter information such as:

• care provided
• how long the care took
• how much the client helped with the care

In some provinces, these data help determine facility funding.

Other workplaces place computers at nursing stations. Some community agencies use handheld digital devices to keep client information current.

Accuracy and Consistency Matter

Whether you record on paper or electronically, information needs to stay clear and thorough.

Key fact: Measurements and numbers must be accurate.

When space is available for observations:

• describe the observation precisely
• record relevant information
• focus on facts
• avoid third-person wording

For example, a factual entry would identify an abrasion measuring 5 cm by 3 cm on the left knee instead of writing a first-person statement about seeing it.

Charting forms part of a legal document. Standardized and accurate documentation matters when legal claims involve malpractice, neglect, or other negative actions.

Rules for All Documentation

Follow these general documentation rules:

• Use only employer-approved abbreviations.
• Use correct spelling, grammar, and punctuation.
• Record only what you observed and performed.
• Never chart a procedure or treatment before completing it.
• Keep entries accurate, concise, and factual.
• Do not record assumptions or opinions.
• Record information logically and in the order events occurred.
• Use clear descriptions and avoid words with more than one meaning.
• Record the client’s exact words when needed and place direct quotes inside quotation marks.
• Report changes in the client’s previously reported condition.
• Report that you informed your supervisor and the time you made the report.
• Do not leave out information.
• Record safety measures used during care.

Every submitted record, whether paper or electronic, forms part of the legal record and might appear in legal proceedings involving the worker or employer.

Rules for Written Documentation

When completing written documentation:

• Always use ink.
• Follow employer policy for ink colour.
• Keep writing neat and legible.
• Include the date and time with each entry.
• Follow employer policy for conventional or 24-hour time.
• Never erase an error or use correction fluid.
• Draw one line through an error.
• Write error or mistaken entry above the mistake.
• Add your initials.
• Rewrite the corrected information.
• Follow any additional employer correction policy.
• Sign every entry.
• Include your title when employer policy requires it.
• Do not skip lines.
• Draw a line through unused space on a partly completed line or through the rest of a page.
• Make sure each form is stamped with the client’s name and other identifying information.

Drawing a line through unused space prevents another person from adding information beside your signature.

Rules for Electronic Documentation

Electronic documentation has extra security and equipment rules.

• Log in using only your own personal identification number, or PIN.
• Never share your PIN.
• Keep other people from seeing your PIN while you log in.
• Document only what you observed, were told, or did.
• Never document as a favour for another person.
• Use only employer-approved abbreviations.
• Use correct spelling, grammar, and punctuation.
• Learn the electronic system used by your agency and where information belongs.
• Attend the training classes offered for the system.
• Keep food and drinks away from computers and electronic devices.
• Do not drop handheld devices.
• Do not leave devices in a car, where theft or temperature changes create problems.
• Protect confidentiality by turning a visible monitor away from other people.

Recording Time With the 24-Hour Clock

The 24-hour clock uses four digits.

The first two digits show the hour. The last two digits show the minutes.

Examples:

• 0100 = 1:00 a.m.
• 1300 = 1:00 p.m.
• 0110 = 1:10 a.m.
• 1400 = 2:00 p.m.
• 2035 = 8:35 p.m.

For afternoon and evening times, add 12 to the conventional hour. For example, 2:00 p.m. becomes 1400.

The abbreviations a.m. and p.m. are not used with 24-hour time. Some workplaces use h or hr. Follow employer policy.

Using the 24-hour clock reduces confusion between morning and afternoon times.

Conventional Time	24-Hour Clock
1:00 a.m.	0100
2:00 a.m.	0200
3:00 a.m.	0300
4:00 a.m.	0400
5:00 a.m.	0500
6:00 a.m.	0600
7:00 a.m.	0700
8:00 a.m.	0800
9:00 a.m.	0900
10:00 a.m.	1000
11:00 a.m.	1100
12:00 noon	1200
1:00 p.m.	1300
2:00 p.m.	1400
3:00 p.m.	1500
4:00 p.m.	1600
5:00 p.m.	1700
6:00 p.m.	1800
7:00 p.m.	1900
8:00 p.m.	2000
9:00 p.m.	2100
10:00 p.m.	2200
11:00 p.m.	2300
12:00 midnight	2400 or 0000

Medical Terms and Abbreviations

Health care workers use medical terminology and abbreviations to communicate clearly.

If another team member uses a word you do not understand, ask what it means. Keeping a medical dictionary nearby also helps with unfamiliar terms.

All health care team members must use only terms and abbreviations approved by employer policy. This supports consistent interpretation across the team.

Methods of Charting

Agencies and facilities use different charting methods.

Narrative Charting

Narrative charting records client information and care in chronological order ⓘ.

The entry reads like a log of the client’s day.

SOAP Charting

SOAP uses four components:

• S: subjective data
• O: objective data
• A: analysis or assessment of the data
• P: plan of care

PIE Charting

PIE uses three components:

• P: problem
• I: intervention
• E: evaluation

ADPIE Charting

ADPIE adds two components to PIE:

• A: analysis
• D: diagnosis

The PIE components remain:

• P: problem
• I: intervention
• E: evaluation

DAR Charting

DAR uses three components:

• D: data or diagnosis
• A: analysis and action
• R: response

Other charting methods are also used across Canada. Instructors train students on the method used in their area.

Recording in a Facility

In most acute-care settings ⓘ, you will be required to document your care electronically using a computer program. When computers are unavailable, you may be required to record your care in writing.

In long-term care, you may document your care electronically, on ADL checklists, or on flow sheets. You may also be expected to give summary reports on care provided to clients.

Recording in the Community

Agencies and case managers keep most client charts at their organizations. Parts of the chart are often kept in the client’s home, usually in a binder.

Depending on agency policy and the client’s needs, the binder often contains:

• the care plan
• progress notes
• ADL checklists
• flow sheets
• task sheets

Some agencies use smartphones or tablets for documentation.

Agency policies differ. Some agencies do not allow support workers to enter information into the client record. Others expect support workers to record tasks and observations.

Community Task Sheets

Most community agencies use client care task sheets or electronic sections serving the same purpose.

The support worker starts a new task sheet for each client. As tasks are completed, the worker checks the appropriate areas.

Task sheets often include space for:

• special circumstances
• observations
• whether the client acted independently
• whether the client depended on help
• whether the client needed some assistance

A verbal report is a spoken account of care provided and observations made.

Report: Changes in the client’s normal functioning or condition should be reported by phone to the supervisor.

Record on the task sheet:

• verbal reports you gave
• phone instructions received from the supervisor

Completed task sheets are handed in, stored in the correct place, or electronically submitted weekly or monthly according to agency policy.

Work-expense forms, such as vehicle mileage records, are also submitted according to agency policy. Supervisors use task sheets when preparing client reports and sometimes request extra information.

Confidentiality

Support workers have an ethical and legal duty to keep client information confidential.

This duty covers information recorded:

• by hand
• on a computer
• on another electronic device

All employers have strict guidelines about client-record confidentiality. You must be particularly careful to follow guidelines for accessing, reporting, and transporting information according to provincial or territorial regulations. Federal guidelines also protect individual privacy.

Only health care team members directly involved in the client’s care have access to confidential information.

Workers who usually do not need access include:

• housekeeping staff
• kitchen staff
• office clerks

In home care, only certain family members have access to client information. The supervisor identifies who is allowed to see the record.

Transporting Confidential Records

A worker sometimes carries documents between a central file area and another location in a facility. Community workers also carry confidential client information.

Stay focused while transporting records. A distraction creates the risk of leaving confidential documents in the wrong place.

Electronic Communication and Health Records

Electronic communication has changed how health information is researched, shared, and documented.

Internet search engines do not screen health information for accuracy and reliability. Government websites and telephone services provide reliable sources for health care questions.

In remote areas, health workers sometimes send client health information electronically to nurse practitioners, doctors, or health teams located far away.

Electronic health records are easy for health care providers to read and respond to. They also help connect clients in remote areas with health care services.