Cover image for: Report Writing in Patient Health Records
Details
CPD1h 40m of CPD
Rating
4.7
Total Rating(s)203
Publish Date03 May 2018
Review Date23 January 2021
Expiry Date03 May 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)203
Publish Date03 May 2018
Review Date23 January 2021
Expiry Date03 May 2021
Recorded InMelbourne, Australia
Topic Tags
Professional Practice Issues
Legal
Technology
Patient Safety
Professional Issues
Communication
Documentation
Disclaimer

Further Learning

Learner Reviews

4.7

203 Total Rating(s)

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Angharad Wyn jones
21 Feb 2019

Interesting.

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Shazia Sabreen Ali
19 Feb 2019

Good examples of case studies

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Leona Doherty
18 Feb 2019

Good, lady was a little dry and could have injected more interest into the webinar

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Dianne Walsh
17 Feb 2019

This online training covered the topics of professional practise issues, legal, technology, patient safety and professional issues. It provided me with the new knowledge and reinforced existing knowledge and will be directly transferable to my work.

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Wendy Thornton
17 Feb 2019

Excellent, I will be encouraging all the clinical staff in my area to complete this module

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peta O'Meagher
16 Feb 2019

great refresher and reminder of the consequences of not recording patient notes in a professional, accurate and timely manner

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Gemma Rizzi
15 Feb 2019

Easy to follow. Like the use of case studies to help put the information into light of practice

Portrait of Vicki Law
Vicki Law
15 Feb 2019

This course reinforced that I am correctly following procedures with note recording in patients/clients notes.

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May Black
14 Feb 2019

I recommend this course as a refresher to documentation. The course was presented is very well presented and relevant to our scope of practice.

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Limor Weingarten
14 Feb 2019

The importance of documenting correctly