Cover image for: Report Writing in Patient Health Records
Details
CPD1h 40m of CPD
Rating
4.7
Total Rating(s)587
Published03 May 2018
Updated12 February 2019
Reviewed18 January 2021
Recorded InMelbourne, Australia

Course Overview

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.

Topics include:

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

Target audience

All health professionals given the critical need for corerct documentation to underpin safe practice.

Purpose

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.

Need

An essential element of documentation is to provide a record of continuity of care. When documentation is done well the patient’s record also serves as an effective tool of communication amongst the team.

Ocacssionally, records will be needed in a court or tribunal as evidence. 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 provided.

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 your communication in patient care records
  • Describe consent requirements for photo/video recordings and how the images are incorporated in the patient's health record to ensure patient rights are protected

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

Portrait of Linda Starr
Linda Starr

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.

Details
CPD1h 40m of CPD
Rating
4.7
Total Rating(s)587
Published03 May 2018
Updated12 February 2019
Reviewed18 January 2021
Recorded InMelbourne, Australia
Topic Tags
Professional Practice Issues
Legal
Technology
Patient Safety
Professional Issues
Communication
Documentation
Disclaimer

Further Learning

Learner Reviews

4.7

587 Total Rating(s)

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Jade Hall
15 Jun 2019

Good content selected for this course, very informative with great case studies used.

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Anne nugent
14 Jun 2019

Case studies best

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wendy Buggy
14 Jun 2019

This resource was excelent. It was very clear in the expectations and responsibility in keeping detailed progressive and accurate notes. The case studies were of great benefit to understand the ramifications of poor communication including insufficient note writing and the care and integrity of patient records.

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Catherine Langdon
11 Jun 2019

Very informative and helpful

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Janna Jeline Aguilar
08 Jun 2019

ok

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Eleanor Jansen
07 Jun 2019

This course has helped me to be cautious when documenting important information as the outcome could impact the integrity of the whole organisation.

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Nicole Louise Williams
07 Jun 2019

This is a great reminder of the importance of documenting and gaining consent.

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Rani Sivaprasad
06 Jun 2019

An excellent video

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Caiqin Mao
06 Jun 2019

this is a good CPD, refresh my knowledge as well as tell me how to deal with some delimmas in the case studies.

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Margaret Ann Shevlin
05 Jun 2019

Excellent refresher partuclarly from the perspective of legal obligations and implications