Report Writing in Patient Health Records
This Course will provide nurses and midwives with an overview of what is considered to be effective communication through documentation in the patient’s record, and what adverse outcomes can occur when this is done poorly.
ActAct on the importance of adequate and accurate documentation to communicate patient information and ensure patient safety
UseUse knowledge of judicial interpretation of inadequate documentation to improve your communication in patient care records
DescribeDescribe consent requirements for photo/video recordings and how the images are incorporated in the patient's health record to ensure patient rights are protected
Dr Linda Starr is a general and mental health qualified nurse, lawyer, and associate professor in the School of Nursing and Midwifery at Flinders University. Her research interests have been in health law for health practitioners, criminal law, forensic health care, and elder abuse investigation and prosecution, which was the subject of her PhD. Linda is currently the chair of the state board of the Nursing and Midwifery Board, Australia, the director on the Board of Directors at the Aged Rights Advocacy Service, and is the founding president of the Australian Forensic Nurses Association. She has an extensive speaking record, nationally and internationally, on issues in health law, forensic nursing, and elder abuse.
- The important role of documentation
- The basics of documentation
- Case studies
- Poor versus quality documentation
Primarily 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 health care setting. However, other health professionals and those working in management and education will also find this information valuable.
Provide nurses and other healthcare professionals with principles for effectively communicating patient care in documentation by written words, or other means such as photography/video footage, using examples that have been examined by the Courts.
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 in indication for the need for a performance review of the practitioner. As such it is critical for nurses and midwives 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.
Health professionals in Australia that are registered with AHPRA are required to obtain continuing professional development (CPD) hours/points each year that relates to their context of practice, in order to comply with mandatory regulatory requirements.