Clinical Documentation and Patient Health Records | Seneca Nanji Foundation School of Nursing | Seneca Students

Clinical Documentation and Patient Health Records

Accurate and timely clinical documentation is an essential responsibility of all students participating in clinical practicum. Patient health records are legal documents used to communicate care, support clinical decision-making and promote continuity of care among healthcare professionals.

Students in the Seneca Nanji Foundation School of Nursing must document patient care in accordance with their program requirements, level of competency, clinical agency policies and applicable professional standards.

Documentation Standards and Expectations

Students are expected to maintain accurate, complete and objective clinical records while working within their authorized role and level of supervision.

Students must:

• Document patient assessments, observations, interventions and care provided accurately and in a timely manner.

• Record only care, procedures and observations they have personally performed or witnessed, as appropriate to their responsibilities.

• Follow the clinical agency's documentation procedures, including requirements for electronic health records.

• Ensure documentation is completed using their own authorized credentials and appropriate professional or student designation.

• Correct documentation errors using the clinical agency's approved procedures without concealing or altering the original record.

• Maintain patient privacy and confidentiality in accordance with applicable legislation and clinical agency policies.

Falsification of Patient Health Records

Falsification, fabrication or deliberate alteration of patient health records is strictly prohibited and constitutes a serious breach of professional and ethical responsibilities.

Examples include documenting care or assessments that were not performed, recording medications or treatments that were not administered, entering inaccurate or fabricated patient information, altering records to conceal errors, documenting on behalf of another individual without authorization or using another person's credentials to access or complete patient records.

Students must never modify, delete or conceal clinical documentation to misrepresent patient care or clinical activities.

Reporting Documentation Errors

Students must immediately notify their Clinical Supervisor and follow the clinical agency's reporting procedures if they identify an error, omission or inaccurate entry in a patient health record.

Documentation errors must be corrected using the agency's approved process. Students must never attempt to conceal an error or independently alter another healthcare professional's documentation.

Consequences of Unsafe or Falsified Documentation

Falsification of patient health records may constitute unsafe or unprofessional clinical practice and a violation of Seneca Polytechnic's academic and student conduct policies.

Students who engage in falsification of clinical documentation may be removed from the clinical setting and subject to formal review under the School of Nursing's Unsafe/Unprofessional Clinical Practice procedures.

Depending on the findings and severity of the incident, consequences may include an Unsatisfactory (UNSAT) grade in the clinical course, academic probation, mandatory remediation or withdrawal from the program.

Incidents may also be subject to investigation by the clinical placement agency and, where applicable, relevant professional regulatory authorities.

Professional Standards and Legislation

Students must comply with applicable clinical documentation requirements, including:

• College of Nurses of Ontario (CNO) – Standards & Guidelines – Choose the Documentation Standard. Establishes professional expectations for accurate, timely and secure nursing documentation.

• Personal Health Information Protection Act, 2004 (PHIPA) – Establishes legal requirements for the protection and appropriate handling of personal health information.

• Seneca Polytechnic – Academic Integrity Policy – Addresses falsification, fabrication and misrepresentation of records and academic information.

• Seneca Polytechnic – Student Code of Conduct – Establishes expectations for honesty, accountability and responsible student conduct.

Students must also comply with the documentation, privacy and patient safety policies of their assigned clinical placement agency.

Accurate clinical documentation is a fundamental requirement of safe patient care and professional accountability. Falsification or deliberate misrepresentation of patient health records will not be tolerated.