Documentation and Report Writing

Cover image for: Documentation and Report Writing
CPDTime.
1h 16m
Updated 27 Jun 2024 Certificate ANCC Accredited

This Ausmed Course will provide an overview of what is considered to be effective communication through documentation in the patient’s record, and what adverse outcomes can occur when done poorly.

Content

5 Video Units • 16 Questions
Introduction
2m
Pretest
3 Questions
The Important Role of Documentation and Patient Records
4 Questions
15m
The Basics of Documentation
4 Questions
16m
Case Studies
1 Question
16m
Poor v Quality Documentation
2 Questions
10m
Pre-reflection
1 Question
Post-reflection
1 Question

What you'll learn:

1

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

2

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

3

Describe consent requirements for photo/video recording and how the images are incorporated in the patient’s health record to ensure patient rights are protected.

Who it's for:

This Ausmed Course is relevant to all 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 healthcare setting. However, other health professionals and those working in management and education will also find this information valuable.

Why it's needed:

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 an indication of the need for a performance review of the practitioner. As such, it is critical for healthcare professionals 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.

Purpose

Provide nurses and other healthcare professionals with principles to effectively communicate patient care in written documentation or other means, such as photography/video footage, using examples that have been examined by the Courts.

Topics

Content Integrity
Ausmed strives for the highest level of content integrity and accuracy in our educational resources.
Timeline
This resource will be updated or unpublished after the due for review date.
Last updated27 Jun 2024

Published03 May 2018

Due for review30 Jul 2024
ANCC Accredited
This course has been published with the American Nurses Credentialing Center Accreditation.
Accreditation Badge
Accreditation Information
Disclaimer
Usage
Cite this resource
Disclosure
Anyone involved in the creation of Ausmed content declare that they have no conflicts of interest. Generic or non-proprietary names of medications or products have been used where possible.

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