1h 40m

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.

03 May 2018

Learning Outcomes

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

Comments

SImple, excellent content and explanation. -- 23 May 2018
Excellent resource -- 23 May 2018
I found this resource was very engaging and explained the procedure of correct documentation so well and easy to understand -- 23 May 2018
Very enjoyable. Everyone in the healthcare industry can do with refreshers in the area of documentation. -- 23 May 2018
enjoyable course to do -- 23 May 2018
Good info, very important part of nursing. -- 22 May 2018
Very informative -- 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. -- 22 May 2018
Really great course, answered all my questions regarding documenting and I highly recommend. -- 22 May 2018
A good overview I would recommend this course. -- 22 May 2018
Excellent, clear and precise!! -- 21 May 2018
Very informative presentation, very enjoyable. -- 21 May 2018
good -- 20 May 2018
Informative -- 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. -- 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. -- 20 May 2018
Definitely worth while for all clinicians -- 19 May 2018
Excellent -- 19 May 2018
Great reminder of how to do something we do every shift but is so important. -- 19 May 2018
Recommended to all health professionals. -- 18 May 2018
Excellent course -- 18 May 2018
This VLA is very educative therefore all health care workers need to watch it. -- 17 May 2018
Very informative and excellent case studies -- 17 May 2018
A good refresher on the importance of clear and timely documentation -- 17 May 2018
Very informative. Very good presentation. -- 17 May 2018
Absolutely terrific. Very informative. -- 17 May 2018
Very informative. Great presenter -- 17 May 2018
Great presentation -- 17 May 2018
Very informative and engaging -- 17 May 2018
A well presented education topic on documentation. -- 17 May 2018
great information. -- 16 May 2018
i't very interesting! -- 16 May 2018
I have learned the importance of documentation in healthcare settings. -- 16 May 2018
excellent -- 16 May 2018
excellent education -- 16 May 2018
Excellent -- 16 May 2018
The speaker is very engaging and the topic is very interesting and helpful. -- 15 May 2018
very good presentation -- 15 May 2018
Have given a good semple of scenario to elaborate the inportance of good documentation. -- 15 May 2018
So easy to understand and very informative -- 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. -- 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 -- 15 May 2018
Often overlooked... -- 14 May 2018
very detailed and informative -- 14 May 2018
good -- 14 May 2018
This was informative and useful -- 14 May 2018
Very informational documentation. -- 14 May 2018
good -- 14 May 2018
Extremely appropriate & relevant information, which I require to implement in my daily work on a busy ward. -- 14 May 2018
very good -- 14 May 2018
Very interesting and well Presented -- 13 May 2018
I found this session interesting, relevant to practice, well presented with good examples and clear information. I would recommend to peers. -- 13 May 2018
Excellent presentation, case studies were very interesting and thought provoking -- 13 May 2018
excellent very well presented -- 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. -- 13 May 2018
A great refresher and always good to be reminded of our legal obligations -- 13 May 2018
Clear presentation with good use of case studies to support theory. -- 12 May 2018
Very well presented and very relevant to our everyday work -- 12 May 2018
This topic is always a timely reminder of the importance to follow organisational policy.Its there for a reason. -- 12 May 2018
educator engaging recommend to my colleagues -- 11 May 2018
IT WAS WELL PRESENTED UP TO THE POINT; HOWEVER IN AGED CARE SHORTAGE OF STAFF IS A ISSUE? -- 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 -- 10 May 2018
Very informative -- 10 May 2018
Good educational resource -- 10 May 2018
The importance of this activity is well-founded-and it's interesting as well. -- 10 May 2018
A very good presentation -- 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. -- 10 May 2018
great -- 10 May 2018
The topic was clearly delivered by the educator. -- 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. -- 09 May 2018
good -- 09 May 2018
Very good, especially interesting with the actual case reviews. -- 09 May 2018
Well presented subject. -- 09 May 2018
This training reminds us how important our report writing is to all parties. Session easy to understand. -- 09 May 2018
The cpd was very helpful and informative -- 09 May 2018
A great refresher for all health professionals -- 08 May 2018
Excellent presentation. Presenter is very clear and knowledgeable. Recommend this for all health care professionals. -- 08 May 2018
Interesting and very relevant to our work. -- 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. -- 08 May 2018
n -- 08 May 2018
Well worth reviewing -- 08 May 2018
I found this to most resourceful and provided additional information about documentation. -- 08 May 2018
I found this course extremely helpful and relevant. -- 08 May 2018
It was good to learn with case studies. -- 08 May 2018
Very informative and a must for everyone. -- 08 May 2018
good -- 08 May 2018
This topic was very engaging. -- 07 May 2018
I enjoyed this learning. Everyone needs to view this at some stage. -- 07 May 2018
very good -- 07 May 2018
excellent -- 07 May 2018
A good refresher course on the value of quality documentation when you need it! -- 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. -- 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 -- 06 May 2018
good session -- 06 May 2018
great -- 05 May 2018
The educator was engaging and I would recommend this to other health professionals -- 05 May 2018
I would recommend this education -- 04 May 2018
Very informative. Great presentation. Would love to see this presenter again. it was a very engaging module. -- 04 May 2018
good -- 04 May 2018

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.