Course Overview

In any healthcare organisation, accurate documentation detailing all aspects of a consumer’s care is an essential way of communicating care and services provided, the outcomes of this care, and any changes in the consumer’s needs and preferences. This Ausmed Training Module will provide you with basic fundamental skills for keeping effective documentation in both residential and home care environments.

Topics

• Why is documentation important?
• What is the AN-ACC and how does it relate to documentation?
• What are your documentation responsibilities?
• When and where should documentation occur?
• What guidelines and frameworks should be used when documenting?
• A look at SOAP and ISOBAR for communicating clinical information.
• What information should be included in documentation.

Learning Outcomes

• Understand why effective documentation is important.
• Know where and when to document.
• Know how to document.
• Know what to include in your documentation.

Target Audience

All healthcare workers and professionals working in any aged care setting.

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.

Educators

Presented by

Ausmed View profile

Ausmed’s editorial team is committed to providing high-quality, well-researched and reputable education to our users, free of any commercial bias or conflict of interest. All education produced by Ausmed is developed in consultation with healthcare professionals and undergoes a rigorous review process to ensure the relevancy of all healthcare information and updates to changes in practice. If you have identified an issue with the education offered by Ausmed or wish to submit feedback to Ausmed's editorial team, please email ausmed@ausmed.com.au with your concerns.

Peer reviewed by

Linda Starr View profile