Course Overview

This Ausmed Course will provide an overview of what is considered to be effective communication through documentation in the patient’s record, and what adverse outcomes can occur when done poorly.

Topics

• The important role of documentation
• The basics of documentation
• Case studies
• Poor versus quality documentation

Need

Perhaps the most important role of documentation is to provide a record of continuity of care. In today’s healthcare system, patients are likely to have a range of health professionals providing different aspects of their care. When documentation is done well the patient’s record also serves as an effective tool of communication amongst the team. However, from time to time the patient’s record will be needed in a court or tribunal as evidence in coronial inquiries, criminal or civil matters, or tribunal hearings.

Furthermore, poor documentation can serve as an indication of the need for a performance review of the practitioner. As such, it is critical for healthcare professionals to understand how these judicial forums will interpret not only what is written in the record but also what is not, and how this may reflect upon them as a health professional and the quality and standard of care they have delivered.

Purpose

Provide nurses and other healthcare professionals with principles to effectively communicate patient care in written documentation or other means, such as photography/video footage, using examples that have been examined by the Courts.

Learning Outcomes

• Act on the importance of adequate and accurate documentation to communicate patient information and ensure patient safety.
• Use knowledge of judicial interpretation of inadequate documentation to improve communication in patient care records.
• Describe consent requirements for photo/video recording and how the images are incorporated in the patient’s health record to ensure patient rights are protected.

Target Audience

This Ausmed Course is relevant to all nurses and midwives working in any clinical setting, whether this is in acute care, aged care, in the community, or with vulnerable populations within any healthcare setting. However, other health professionals and those working in management and education will also find this information valuable.

Disclosure

No conflict of interest exists for anyone in the position to control content for this activity. Wherever possible, generic or non-proprietary names of medications or products have been used.

Educator

Linda Starr View profile

Dr Linda Starr (PhD) is an associate professor in the College of Nursing and Health Sciences at Flinders University. She has extensive experience as a registered nurse and in nursing and midwifery regulation through her previous role as Chair of the State Nursing and Midwifery of Australia Board and the SA practitioner member on the National Nursing and Midwifery Board of Australia. Linda is passionate about the intersection between healthcare and the law, with a particular focus on the mandatory reporting of elder abuse.