1h 40m
Linda Starr
03 May 2018

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.

Act

Act on the importance of adequate and accurate documentation to communicate patient information and ensure patient safety

Use

Use knowledge of judicial interpretation of inadequate documentation to improve your communication in patient care records

Describe

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

Educator

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.

Comments

Phillimon Chiware06 Sep 2018
This was an eye opener ,great time spend,worth it

Lauren Crawford06 Sep 2018
Helpful information in the importance of report writing.

Chunling Yang01 Sep 2018
educational and insightful

Sharon Fahey26 Aug 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.

Beverly Salt18 Aug 2018
record keeping is a vital and legal.lzrt of what we do.it .ist be right first-time

XIAO YANG07 Aug 2018
Great topic

Sarah Stenson02 Aug 2018
Interesting cases presented

Vidya Vikram31 Jul 2018
It was really encouraging

Patrick Yam21 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

Kristy Beckett16 Jul 2018
Excellent information. Well presented.

Sarah McAllen11 Jul 2018
Very practical information. Good case examples.

Bowen Rao10 Jul 2018
perfect

Tanya Volzke04 Jul 2018
Great content

Leesa Weber04 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.

Raeleen Mundey02 Jul 2018
Very helpful, concise reminder on the importance of good documentation.

Lisa Harper26 Jun 2018
Found this education very informative and relevant to practice

Elly Jasprizza19 Jun 2018
Very clearly spoken and easy to follow and understand

Helen Bridget Wilson15 Jun 2018
I found this very interesting and informative, the format good and the presenter clear and precise

Frances Browne14 Jun 2018
Good refresher for all nurses.

Sharon Neale13 Jun 2018
This is a great refresher for the importance of accurate and concise documentation.

joshua bold11 Jun 2018
1

Maureen Huggins11 Jun 2018
Informative presentation

Maureen Huggins11 Jun 2018
Informative presentation

Soumyamol Binesh08 Jun 2018
Good

Terry woods04 Jun 2018
Much needed course for both new and experienced nurses.

Georgia Jones03 Jun 2018
very informative and valuable

Bec Ozols02 Jun 2018
Good overview on correct documentation

Kerry Terry31 May 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.

Lindsay Barrell Tellis31 May 2018
very informative

Patricia Hurst31 May 2018
Very comprehensive imformation

Navjot Thind31 May 2018
Very good!

Kerh hollyman31 May 2018
Great refresher

Adam Whitemore31 May 2018
An excellent presentation which highlighted essential information

Maree Augostin31 May 2018
Excelent

Kristie-Lee Perrott31 May 2018
useful information was provided. Instructor easily understood.

Sirini Prathibha Ariyarathna Korale Kankanamge31 May 2018
Excellent

Valerie Courreges30 May 2018
Fantastic refresher

Susan ingall30 May 2018
Very informative.

Rita edbrooke30 May 2018
Very well presented course, recommended for all health care professionals.

Narelle Odwyer30 May 2018
great!

karen nolan30 May 2018
The educator was very clear in what she was addressing and made the content easy to understand

Bronwyn chappel30 May 2018
fabulous

Margaret Smith29 May 2018
An important resource for every nurse. Very interesting, informative and articulate.

Melinda coad29 May 2018
I could listen to Linda starr all day, case studies reinforce relevance

Claire Jacobs29 May 2018
This was a very knowledgeable video.

HARPREET KAUR29 May 2018
importance of right documentation at the right time.

GAEL HOLDSWORTH28 May 2018
Relevant information, using both paper & electronic documentation, reflective of recent legal cases, suggestive of best practice.

Avelina Go Chow28 May 2018
Very informative and relevant to our nursing profession and other health professionals

Olivia Collins 28 May 2018
This educator has helped reinforce my knowledge of documentation and provided extensive information.

Deborah Marmo28 May 2018
appreciate this to re-enforce the need for excellent and precise documentation.

Nicholas Stewart Cleave28 May 2018
Fantastic, I love these new learning tools / activities

Deborah French28 May 2018
Excellent presentation. Thank you

Natalie Jane Wilson27 May 2018
A good session to reinforce the importance of accurate documentation.

Jessica Arnold27 May 2018
.

Robyn Poga27 May 2018
This was what I needed very informative, helpful, not to much overload.

Karen Innes26 May 2018
Provided useful information surrounding our roles and responsibilities in documentation. Interesting case studies to emphasise points.

Debra Ambrosini26 May 2018
This course was a great refresher into report writing and documentation.

Julianne Jackson26 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.

lizhen lin25 May 2018
Great presentation, very informative

Karren Sedano25 May 2018
Excellent topic!

Gillian Carne25 May 2018
Great information

Joseph Espejo25 May 2018
the speaker being an rn and a lawyer, makes an impression of being well versed on the topic at hand

Tupou Makasini25 May 2018
Great video outlining the importance of documentation.

Nicole Lynch25 May 2018
Excellent educational tool for the importance of accurate documentation and encouraging best practice within this area of the health care profession.

Ruth Curtis25 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.

Jonathan Wood24 May 2018
Interesting learning

tracey lackmann24 May 2018
Excellent presentation

Cecily Condon24 May 2018
Recommend to anyone working in healthcare.

Carole kathleen Brown24 May 2018
Well worth participating in this CPD

Nicole Ferreira24 May 2018
This was a very eye opening topic and one where I think as nurses we might get a little slack in

Krishna paudel24 May 2018
good activity

Louise Morosi24 May 2018
A very detailed and quite well humored learning on note taking with case histories and legal implications.

Babaldeep Singh23 May 2018
SImple, excellent content and explanation.

Danielle Wohling23 May 2018
Excellent resource

Leeanne Davie23 May 2018
I found this resource was very engaging and explained the procedure of correct documentation so well and easy to understand

Katrinna Brooks23 May 2018
Very enjoyable. Everyone in the healthcare industry can do with refreshers in the area of documentation.

Samantha Whitehouse23 May 2018
enjoyable course to do

Elizabeth Uhlmann22 May 2018
Good info, very important part of nursing.

Alex Cooper22 May 2018
Very informative

keryn laidlaw22 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.

Kristy Nivison22 May 2018
Really great course, answered all my questions regarding documenting and I highly recommend.

Jacqueline Curran22 May 2018
A good overview I would recommend this course.

Agnes Namute21 May 2018
Excellent, clear and precise!!

Graham Jones21 May 2018
Very informative presentation, very enjoyable.

VALENTINE JEPKEMBOI20 May 2018
good

Kulbir kaur20 May 2018
Informative

Jason Ballard20 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.

Carmel Green20 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.

Jo Teague19 May 2018
Definitely worth while for all clinicians

Roshita Reji Rachel19 May 2018
Excellent

Nerissa Moore19 May 2018
Great reminder of how to do something we do every shift but is so important.

Harry Prosser18 May 2018
Recommended to all health professionals.

Lisa Lising Reyes18 May 2018
Excellent course

Dancan Kapkusha17 May 2018
This VLA is very educative therefore all health care workers need to watch it.

Maria Ives17 May 2018
Very informative and excellent case studies

Mary Rothery17 May 2018
A good refresher on the importance of clear and timely documentation

Suzanna Potter17 May 2018
Very informative. Very good presentation.

Dorothy-anne burrows17 May 2018
Absolutely terrific. Very informative.

Hellene Heron17 May 2018
Very informative. Great presenter

Marian Galpin17 May 2018
Great presentation

Rincy Aijo17 May 2018
Very informative and engaging

Mark James17 May 2018
A well presented education topic on documentation.

Sukhvinder Singh Birdi16 May 2018
great information.

Anna Roxas16 May 2018
i't very interesting!

Karamjeet Kaur16 May 2018
I have learned the importance of documentation in healthcare settings.

yan zhang16 May 2018
excellent

Sallianne Reed16 May 2018
excellent education

James Cooke16 May 2018
Excellent

Sheila Mae Erni15 May 2018
The speaker is very engaging and the topic is very interesting and helpful.

Harsimrat Kaur15 May 2018
very good presentation

Iana Villacastin15 May 2018
Have given a good semple of scenario to elaborate the inportance of good documentation.

Phoebe tsourdalakis15 May 2018
So easy to understand and very informative

Annette richards15 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.

Catherine therese Simpson15 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

George Xian14 May 2018
Often overlooked...

Kristel Mae Castaneda14 May 2018
very detailed and informative

Tong Li14 May 2018
good

Christine Pan14 May 2018
This was informative and useful

Elodie Bouchard14 May 2018
Very informational documentation.

Jinju Rajeev14 May 2018
good

Phillipa OBrien14 May 2018
Extremely appropriate & relevant information, which I require to implement in my daily work on a busy ward.

mary susan delos reyes14 May 2018
very good

Rita Burma13 May 2018
Very interesting and well Presented

Heather Egan13 May 2018
I found this session interesting, relevant to practice, well presented with good examples and clear information. I would recommend to peers.

Claire sibson13 May 2018
Excellent presentation, case studies were very interesting and thought provoking

Janette Elliott13 May 2018
excellent very well presented

Geraldine Bound13 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.

Michelle Attard13 May 2018
A great refresher and always good to be reminded of our legal obligations

Pietryna Duch12 May 2018
Clear presentation with good use of case studies to support theory.

Jacqueline Pirouet12 May 2018
Very well presented and very relevant to our everyday work

Helen O'Connor12 May 2018
This topic is always a timely reminder of the importance to follow organisational policy.Its there for a reason.

Jane Wilson11 May 2018
educator engaging recommend to my colleagues

JANKI GOUNDAR10 May 2018
IT WAS WELL PRESENTED UP TO THE POINT; HOWEVER IN AGED CARE SHORTAGE OF STAFF IS A ISSUE?

Andrea Clegg10 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

diane redden10 May 2018
Very informative

Trisha Eisenhuth10 May 2018
Good educational resource

Annabel Holmes10 May 2018
The importance of this activity is well-founded-and it's interesting as well.

Jennifer Ryan10 May 2018
A very good presentation

VANESSA BRIDGET SELMAN10 May 2018
Excellent resource. Case studies really hit the nail on the head with regards to the importance of accurate, timely and informative documentation.

natalie Mielczarek10 May 2018
great

Lourdes Ingebrigtsen09 May 2018
The topic was clearly delivered by the educator.

Kim Szubert09 May 2018
clear, precise and informative. Made me confident that adherence to policy is the only safe route to take when dealing with documentation.

Lin Jiang09 May 2018
good

Margaretha van de Reyt09 May 2018
Very good, especially interesting with the actual case reviews.

Michelle Lipman09 May 2018
Well presented subject.

Naomi Johnston09 May 2018
This training reminds us how important our report writing is to all parties. Session easy to understand.

Angelo Carlo Rontos09 May 2018
The cpd was very helpful and informative

Belinda Blamey08 May 2018
A great refresher for all health professionals

JACINTA KRITIKOS08 May 2018
Excellent presentation. Presenter is very clear and knowledgeable. Recommend this for all health care professionals.

Louise Paul08 May 2018
Interesting and very relevant to our work.

Joachim FERRER08 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.

Caiping Jiang08 May 2018
n

Judy Applegarth08 May 2018
Well worth reviewing

Lesley Smith08 May 2018
I found this to most resourceful and provided additional information about documentation.

Mary Pettitt08 May 2018
I found this course extremely helpful and relevant.

Ellie HWANG08 May 2018
It was good to learn with case studies.

Susan Mitchell08 May 2018
Very informative and a must for everyone.

Lin Wang08 May 2018
good

Denise Whittaker07 May 2018
This topic was very engaging.

Joanne Holloway07 May 2018
I enjoyed this learning. Everyone needs to view this at some stage.

Werner Cossid07 May 2018
very good

Sneha Kuriakose07 May 2018
excellent

Amos Chandiwana07 May 2018
A good refresher course on the value of quality documentation when you need it!

Nicole Gregory07 May 2018
Delivered in a concise, easy to understand format. Good for reinforcing knowledge on why clinical documentation is so important in patient care.

Lynette hodder06 May 2018
The educator was very engaging and I would recommend this to my team good documentation was presented and reinforced with good examples

Reena Raju06 May 2018
good session

Maricel Tuazon05 May 2018
great

Sharon Khan05 May 2018
The educator was engaging and I would recommend this to other health professionals

Raewyn Head04 May 2018
I would recommend this education

Kathryn Hyde04 May 2018
Very informative. Great presentation. Would love to see this presenter again. it was a very engaging module.

Joungsim BAE04 May 2018
good

Course Overview

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.