Course Overview

Brief

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.

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

Topics include:

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

Target audience

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.

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

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.

Educators

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.

Reviews

4.8

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142 Total Rating(s)

Very informative

Deborah Stacey
18 Nov 2018

Relevant and practical, would highly recommend this education.

Deborah King
04 Nov 2018

Very informative.

Julia Blackburn
22 Oct 2018

Very clear and specific presentation. Easy to follow and understand. This is applicable to my role as healthcare provider.

Donna Vic De La Torre
20 Oct 2018

Very good to have a refresher on documentation, it is good to reevaluate what the educator has lectured on the topic.

Sharon Coleman
16 Oct 2018

Excellent resource. Very comprehensive. Recommended for ALL health professionals

Julie McInnis
15 Oct 2018

This was such an eye opening topic and was well presented.

Patricia Camacho
11 Oct 2018

very interesting and engaging I enjoyed the learning from case studies I suggest maybe a few more non hospital based examples would also be helpful

Linda Pye
11 Oct 2018

This topic is gold and for everyone for sure

Kalo Liga
10 Oct 2018

Fantastic resource

Kirsten Boon
10 Oct 2018

Great Lecture

rebecca morrissey
30 Sep 2018

This was an eye opener ,great time spend,worth it

Phillimon Chiware
06 Sep 2018

Helpful information in the importance of report writing.

Lauren Crawford
06 Sep 2018

educational and insightful

Chunling Yang
01 Sep 2018

I would recommend this education to all registered nurses it was very informative and an excellent refresher on the importance of accurate documentation in patient records.

Sharon Fahey
26 Aug 2018

record keeping is a vital and legal.lzrt of what we do.it .ist be right first-time

Beverly Salt
18 Aug 2018

Great topic

XIAO YANG
07 Aug 2018

Interesting cases presented

Sarah Stenson
02 Aug 2018

It was really encouraging

Vidya Vikram
31 Jul 2018

I benefit from this learning. I apply the SOAP and/or SBAR format to write my report. It is important to write an concise and precise patient report. Though it takes time, it avoid the lawsuit and denial registration

Patrick Yam
21 Jul 2018

Excellent information. Well presented.

Kristy Beckett
16 Jul 2018

Very practical information. Good case examples.

Sarah McAllen
11 Jul 2018

perfect

Bowen Rao
10 Jul 2018

Great content

Tanya Volzke
04 Jul 2018

The case studies and dos and don’ts were especially helpful in showing what to do and what not to do when it comes to documentation.

Leesa Weber
04 Jul 2018

Very helpful, concise reminder on the importance of good documentation.

Raeleen Mundey
02 Jul 2018

Found this education very informative and relevant to practice

Lisa Harper
26 Jun 2018

Very clearly spoken and easy to follow and understand

Elly Jasprizza
19 Jun 2018

I found this very interesting and informative, the format good and the presenter clear and precise

Helen Bridget Wilson
15 Jun 2018

Good refresher for all nurses.

Frances Browne
14 Jun 2018

This is a great refresher for the importance of accurate and concise documentation.

Sharon Neale
13 Jun 2018

1

joshua bold
11 Jun 2018

Informative presentation

Maureen Huggins
11 Jun 2018

Informative presentation

Maureen Huggins
11 Jun 2018

Good

Soumyamol Binesh
08 Jun 2018

Much needed course for both new and experienced nurses.

Terry woods
04 Jun 2018

very informative and valuable

Georgia Jones
03 Jun 2018

Good overview on correct documentation

Bec Ozols
02 Jun 2018

A very informative lesson. Staff tend to get a bit lazy about documentation at times. Always remember if it is not documented it did not happen.

Kerry Terry
31 May 2018

very informative

Lindsay Barrell Tellis
31 May 2018

Very comprehensive imformation

Patricia Hurst
31 May 2018

Very good!

Navjot Thind
31 May 2018

Great refresher

Kerh hollyman
31 May 2018

An excellent presentation which highlighted essential information

Adam Whitemore
31 May 2018

Excelent

Maree Augostin
31 May 2018

useful information was provided. Instructor easily understood.

Kristie-Lee Perrott
31 May 2018

Excellent

Sirini Prathibha Ariyarathna Korale Kankanamge
31 May 2018

Fantastic refresher

Valerie Courreges
30 May 2018

Very informative.

Susan ingall
30 May 2018

Very well presented course, recommended for all health care professionals.

Rita edbrooke
30 May 2018

great!

Narelle Odwyer
30 May 2018

The educator was very clear in what she was addressing and made the content easy to understand

karen nolan
30 May 2018

fabulous

Bronwyn chappel
30 May 2018

An important resource for every nurse. Very interesting, informative and articulate.

Margaret Smith
29 May 2018

I could listen to Linda starr all day, case studies reinforce relevance

Melinda coad
29 May 2018

This was a very knowledgeable video.

Claire Jacobs
29 May 2018

importance of right documentation at the right time.

HARPREET KAUR
29 May 2018

Relevant information, using both paper & electronic documentation, reflective of recent legal cases, suggestive of best practice.

GAEL HOLDSWORTH
28 May 2018

Very informative and relevant to our nursing profession and other health professionals

Avelina Go Chow
28 May 2018

This educator has helped reinforce my knowledge of documentation and provided extensive information.

Olivia Collins
28 May 2018

appreciate this to re-enforce the need for excellent and precise documentation.

Deborah Marmo
28 May 2018

Fantastic, I love these new learning tools / activities

Nicholas Stewart Cleave
28 May 2018

Excellent presentation. Thank you

Deborah French
28 May 2018

A good session to reinforce the importance of accurate documentation.

Natalie Jane Wilson
27 May 2018

.

Jessica Arnold
27 May 2018

This was what I needed very informative, helpful, not to much overload.

Robyn Poga
27 May 2018

Provided useful information surrounding our roles and responsibilities in documentation. Interesting case studies to emphasise points.

Karen Innes
26 May 2018

This course was a great refresher into report writing and documentation.

Debra Ambrosini
26 May 2018

Documentation is so important, this learning package was easy to follow & understand I enjoyed doing it. It has definitely helped me in documenting correctly in patients notes.

Julianne Jackson
26 May 2018

Great presentation, very informative

lizhen lin
25 May 2018

Excellent topic!

Karren Sedano
25 May 2018

Great information

Gillian Carne
25 May 2018

the speaker being an rn and a lawyer, makes an impression of being well versed on the topic at hand

Joseph Espejo
25 May 2018

Great video outlining the importance of documentation.

Tupou Makasini
25 May 2018

Excellent educational tool for the importance of accurate documentation and encouraging best practice within this area of the health care profession.

Nicole Lynch
25 May 2018

Good reminder of how everything we do is for permanent record, and how important it is to properly document the care we give the patients.

Ruth Curtis
25 May 2018

Interesting learning

Jonathan Wood
24 May 2018

Excellent presentation

tracey lackmann
24 May 2018

Recommend to anyone working in healthcare.

Cecily Condon
24 May 2018

Well worth participating in this CPD

Carole kathleen Brown
24 May 2018

This was a very eye opening topic and one where I think as nurses we might get a little slack in

Nicole Ferreira
24 May 2018

good activity

Krishna paudel
24 May 2018

A very detailed and quite well humored learning on note taking with case histories and legal implications.

Louise Morosi
24 May 2018

SImple, excellent content and explanation.

Babaldeep Singh
23 May 2018

Excellent resource

Danielle Wohling
23 May 2018

I found this resource was very engaging and explained the procedure of correct documentation so well and easy to understand

Leeanne Davie
23 May 2018

Very enjoyable. Everyone in the healthcare industry can do with refreshers in the area of documentation.

Katrinna Brooks
23 May 2018

enjoyable course to do

Samantha Whitehouse
23 May 2018

Good info, very important part of nursing.

Elizabeth Uhlmann
22 May 2018

Very informative

Alex Cooper
22 May 2018

All health care professionals need to listen to this video, as a constant reminder of the reasons for complete ,professional and accurate documantation, and how it can stand up in a court of law to defend the care you have given.

keryn laidlaw
22 May 2018

Really great course, answered all my questions regarding documenting and I highly recommend.

Kristy Nivison
22 May 2018

A good overview I would recommend this course.

Jacqueline Curran
22 May 2018

Excellent, clear and precise!!

Agnes Namute
21 May 2018

Very informative presentation, very enjoyable.

Graham Jones
21 May 2018

good

VALENTINE JEPKEMBOI
20 May 2018

Informative

Kulbir kaur
20 May 2018

This course was excellent. The information was scaffolded well making good use of a recap of each section including the opportunity to review your learning as you went along as well as the use of real life examples to highlight the concepts which aids in the remembering of the information.

Jason Ballard
20 May 2018

A timely reminder in terms of the possibility of serious outcomes, especially in very busy workplaces where good communication between ALL members of the team is impaired.

Carmel Green
20 May 2018

Definitely worth while for all clinicians

Jo Teague
19 May 2018

Excellent

Roshita Reji Rachel
19 May 2018

Great reminder of how to do something we do every shift but is so important.

Nerissa Moore
19 May 2018

Recommended to all health professionals.

Harry Prosser
18 May 2018

Excellent course

Lisa Lising Reyes
18 May 2018

This VLA is very educative therefore all health care workers need to watch it.

Dancan Kapkusha
17 May 2018

Very informative and excellent case studies

Maria Ives
17 May 2018

A good refresher on the importance of clear and timely documentation

Mary Rothery
17 May 2018

Very informative. Very good presentation.

Suzanna Potter
17 May 2018

Absolutely terrific. Very informative.

Dorothy-anne burrows
17 May 2018

Very informative. Great presenter

Hellene Heron
17 May 2018

Great presentation

Marian Galpin
17 May 2018

Very informative and engaging

Rincy Aijo
17 May 2018

A well presented education topic on documentation.

Mark James
17 May 2018

great information.

Sukhvinder Singh Birdi
16 May 2018

i't very interesting!

Anna Roxas
16 May 2018

I have learned the importance of documentation in healthcare settings.

Karamjeet Kaur
16 May 2018

excellent

yan zhang
16 May 2018

excellent education

Sallianne Reed
16 May 2018

Excellent

James Cooke
16 May 2018

The speaker is very engaging and the topic is very interesting and helpful.

Sheila Mae Erni
15 May 2018

very good presentation

Harsimrat Kaur
15 May 2018

Have given a good semple of scenario to elaborate the inportance of good documentation.

Iana Villacastin
15 May 2018

So easy to understand and very informative

Phoebe tsourdalakis
15 May 2018

very informative and useful education session on what is good and bad documentation. Also very good information to revisit the legalities of appropriate documentation.

Annette richards
15 May 2018

This education is important to all health professionals and a good reminder to be aware of adverse events that can come from inaccuracy. this a really good resource

Catherine therese Simpson
15 May 2018

Often overlooked...

George Xian
14 May 2018

very detailed and informative

Kristel Mae Castaneda
14 May 2018

good

Tong Li
14 May 2018

This was informative and useful

Christine Pan
14 May 2018

Very informational documentation.

Elodie Bouchard
14 May 2018

good

Jinju Rajeev
14 May 2018

Extremely appropriate & relevant information, which I require to implement in my daily work on a busy ward.

Phillipa OBrien
14 May 2018

very good

mary susan delos reyes
14 May 2018

Very interesting and well Presented

Rita Burma
13 May 2018

I found this session interesting, relevant to practice, well presented with good examples and clear information. I would recommend to peers.

Heather Egan
13 May 2018

Excellent presentation, case studies were very interesting and thought provoking

Claire sibson
13 May 2018

excellent very well presented

Janette Elliott
13 May 2018

The Presentation Report Writing is well worth doing, it leaves no stone unturned, it was well presented and the case studies were really good at illustrating the different documenting errors that occur and the outcomes.

Geraldine Bound
13 May 2018

A great refresher and always good to be reminded of our legal obligations

Michelle Attard
13 May 2018

Clear presentation with good use of case studies to support theory.

Pietryna Duch
12 May 2018

Very well presented and very relevant to our everyday work

Jacqueline Pirouet
12 May 2018

This topic is always a timely reminder of the importance to follow organisational policy.Its there for a reason.

Helen O'Connor
12 May 2018

educator engaging recommend to my colleagues

Jane Wilson
11 May 2018

IT WAS WELL PRESENTED UP TO THE POINT; HOWEVER IN AGED CARE SHORTAGE OF STAFF IS A ISSUE?

JANKI GOUNDAR
10 May 2018

Very helpful for new grads and seasoned nurses. Show the importance of correct grammar/spelling as a reflection of one's professional practice

Andrea Clegg
10 May 2018

Very informative

diane redden
10 May 2018

Good educational resource

Trisha Eisenhuth
10 May 2018

The importance of this activity is well-founded-and it's interesting as well.

Annabel Holmes
10 May 2018

A very good presentation

Jennifer Ryan
10 May 2018

Excellent resource. Case studies really hit the nail on the head with regards to the importance of accurate, timely and informative documentation.

VANESSA BRIDGET SELMAN
10 May 2018

great

natalie Mielczarek
10 May 2018

The topic was clearly delivered by the educator.

Lourdes Ingebrigtsen
09 May 2018

clear, precise and informative. Made me confident that adherence to policy is the only safe route to take when dealing with documentation.

Kim Szubert
09 May 2018

good

Lin Jiang
09 May 2018

Very good, especially interesting with the actual case reviews.

Margaretha van de Reyt
09 May 2018

Well presented subject.

Michelle Lipman
09 May 2018

This training reminds us how important our report writing is to all parties. Session easy to understand.

Naomi Johnston
09 May 2018

The cpd was very helpful and informative

Angelo Carlo Rontos
09 May 2018

A great refresher for all health professionals

Belinda Blamey
08 May 2018

Excellent presentation. Presenter is very clear and knowledgeable. Recommend this for all health care professionals.

JACINTA KRITIKOS
08 May 2018

Interesting and very relevant to our work.

Louise Paul
08 May 2018

Very well presented by Dr Linda Starr, who is always brilliant in her teaching nurses about the legal issues relating to health care. Not many nurses will see this as a benefit as there is always the phrase "someone else can deal with this". If i is your patient, then you are responsible for the care that is carried out for your patient. All the text was written in upper case. This is not appropriate as all caps can reduce the readability of the text. The titles and words or short phrases can draw the readers attention to the importance of the following text. A paragraph text should not be in upper case or all small caps.

Joachim FERRER
08 May 2018

n

Caiping Jiang
08 May 2018

Well worth reviewing

Judy Applegarth
08 May 2018

I found this to most resourceful and provided additional information about documentation.

Lesley Smith
08 May 2018

I found this course extremely helpful and relevant.

Mary Pettitt
08 May 2018

It was good to learn with case studies.

Ellie HWANG
08 May 2018

Very informative and a must for everyone.

Susan Mitchell
08 May 2018

good

Lin Wang
08 May 2018

This topic was very engaging.

Denise Whittaker
07 May 2018

I enjoyed this learning. Everyone needs to view this at some stage.

Joanne Holloway
07 May 2018

very good

Werner Cossid
07 May 2018

excellent

Sneha Kuriakose
07 May 2018

A good refresher course on the value of quality documentation when you need it!

Amos Chandiwana
07 May 2018

Delivered in a concise, easy to understand format. Good for reinforcing knowledge on why clinical documentation is so important in patient care.

Nicole Gregory
07 May 2018

The educator was very engaging and I would recommend this to my team good documentation was presented and reinforced with good examples

Lynette hodder
06 May 2018

good session

Reena Raju
06 May 2018

great

Maricel Tuazon
05 May 2018

The educator was engaging and I would recommend this to other health professionals

Sharon Khan
05 May 2018

I would recommend this education

Raewyn Head
04 May 2018

Very informative. Great presentation. Would love to see this presenter again. it was a very engaging module.

Kathryn Hyde
04 May 2018

good

Joungsim BAE
04 May 2018