What information should be included when documenting care time on patient notes?

Documentation of Care Time on Patient Notes

When documenting care time on patient notes, you must include a time-based record with specific timestamps for all interventions, medications administered (with route, site, dosage/kg, and patient effect), vital signs at regular intervals, and the patient's condition at discharge. 1

Essential Time-Based Documentation Elements

During Treatment/Procedure

• Document the exact time of each intervention in a time-based record format 1
• For all medications administered, record:
  • Name of drug 1
  • Route of administration 1
  • Site of administration 1
  • Time of administration 1
  • Dosage per kilogram 1
  • Patient's response/effect 1
• Vital signs monitoring must be documented at specific intervals, including heart rate, blood pressure, respiratory rate, oxygen saturation, and level of consciousness 1
• For sedation procedures specifically, vital signs must be recorded at least every 5 minutes 1

Emergency/Resuscitation Documentation

In emergency situations, despite the difficulty, complete documentation is vital for ongoing care and transfer of care. 1 The American Academy of Pediatrics emphasizes that documentation should include:

• Date and time of treatment 1
• Estimated or actual weight of the child 1
• Medications given with dosages and response noted 1
• Fluid volumes administered 1
• Information or explanations given to the family 1
• Condition of the child at time of departure from the office 1

Post-Treatment/Discharge Documentation

• Record the exact time and condition at discharge 1
• Document that predetermined discharge criteria were met, including level of consciousness and oxygen saturation returning to safe levels 1
• For patients receiving long-acting sedation medications, document extended observation periods due to risk of re-sedation 1

Best Practices for Time Documentation

Metadata and Authentication

The American College of Physicians recommends that clinical documentation includes essential metadata: author information, authentication details, timestamps, and document status 2. This establishes accountability and provides a chronological record of patient care 2.

Efficiency Without Compromising Quality

• Avoid "note bloat" where key findings and timing are obscured by superfluous information 3
• Use problem-oriented documentation that clearly identifies each patient issue with relevant timing 3
• Be cautious with copy-paste functionality as it can propagate outdated timing information 3

Common Pitfalls to Avoid

• Never document retrospectively without noting the delay - timestamps should reflect actual care delivery 2
• Don't use generic template content that doesn't reflect the specific timing of the patient encounter 2, 3
• Avoid redundant documentation of the same timing information in multiple locations 3

Special Considerations

For sedation procedures, the American Academy of Pediatrics mandates a "time out" before sedation to confirm patient identity, procedure, and site, which must be documented 1. During administration, inspired oxygen concentrations and duration of inhalation agents must be documented 1.

The clinical record serves as both a communication tool and legal document 3, making accurate time documentation essential for continuity of care, especially during patient transfers 1.