A program designed to enhance the knowledge of registered nurses and enrolled nurses with regard to documentation responsibilities and legal implications.
This program includes a range of presenters who will look at the differing aspects of nursing documentation and why it is such a crucial aspect of nursing care. It Includes principles underlying the purpose of documentation and pitfalls to be aware of when putting pen to paper. This topic is at the beating heart of all nursing activities and should be included in any comprehensive professional development portfolio. Not to be missed!
Need for Program
There is a need for nurses to discuss the relevance and significance of documentation as a professional tool of communication. Nursing documentation can be viewed from a range of perspectives including risk management, and privacy and the adequacy of current methods of documentation to service these purposes needs to be explored by members of the profession.
Aims and Objectives
The aim of this seminar is to revise key principles of nursing documentation and to discuss major legal implications and contemporary issues relating to what and where nurses write, such as the use of electronic devices for documenting patient care. The theme of accountability reflected in documentation responsibilities will be examined throughout this program.
At the conclusion of this program nurses should be able to:
Reflect on the evidence as to why all types of documentation are crucial elements in high quality patient care activities.
Identify what is needed to consistently present competent and informative written communications.
Explain to a student nurse how nursing accountability for care can be evidenced in appropriate documentation and the significance of this at law.
Day 1
Day 2
Educators
8.30am - Registration and Refreshments
9.00am - The Real Purpose Of Nursing Documentation
Accurate nursing observations when translated into concise yet accurate documentation give a clear picture of the progress – or lack of progress - of patient care. This session looks at the purpose of professional documentation and its importance. It includes:
The contribution that competent documentation makes to nursing care.
How correct documentation minimises risk and protects nurses.
How competent documentation is a mark of professional accountability.
The use of effective written communication skills to convey information accurately yet concisely.
Ethical considerations.
10.30am - Morning Tea and Coffee
11.00am - Fundamentals Of Competent Nursing Documentation
If you didn’t write it then it didn’t happen. Basic principles of English grammar and expression are foundation stones for high quality written communications. Other sound, underlying principles for effective documentation include:
Best ways to document nursing activities.
Why document this and not that?
How frequently should documentation occur?
Who else in the team should document?
What can be documented by non-professional staff?
What is the implication of signing your documented practice? Interactive participation: practise in writing a patient care activity.
12.30pm - Lunch Break and Time to Network
1.30pm - Legal Jeopardy and Valid Written Reporting – What Every Nurse Should Know!
Why are records and documents so highly regarded at law?
What are the implications of poor nursing documentation and do they expose a nurse to inadvertent risk?
How can your documentation assist you to avoid legal jeopardy, such as accusations of malpractice?
What happens to your documentation if it becomes part of a legal case?
For how long is your documentation retained by a health agency?
3.00pm - Afternoon Tea and Coffee
3.30pm - Ownership – Who Owns Your Documentation?
Find out what rights you actually have over what you have written as part of your nursing responsibilities. The following concepts will be explored:
Ownership of documentation – do you own your words?
Getting access to what you have written.
Retention of notes.
Disposal of written records – can you throw away documented material that relates to patient care?
Transferring documentation – can this be done and under which circumstances?
Storage of documentation – privacy and archiving considerations.
4.15pm - Close of Day One of Seminar
9:00am - Start of Day Two
9.00am - Practical Documentation Tips
Documentation is often seen as onerous and time consuming but it need not be so. There are now many short-cuts that can now be made, using clever tools and systems. This interesting session will unmask some of the methods, systems and tools that will help you to effectively and concisely, document your care.
What is stopping us from using tools more effectively?
What value do charts have and what is considered their best use?
10.00am - A Special Look At Incident Reports
A look at the why, when, what and how of reports written by nurses following adverse events.
What must be included in any incident report?
What are the consequences that can occur in a situation where the staff member writing the incident report has poor literacy skills?
10.30am Morning Tea and Coffee
11.00am - Emails – Internet and Hand-Held Devices
The move towards the use of electronic communication for recording patient care and nursing observations is unstoppable. With new technology comes new risk.
What do nurses need to know about electronic confidentiality and privacy?
Email communication – is there ever a case for writing private emails on your work computer?
What special etiquette needs to be considered regarding inter-professional emails?
Should patients be allowed to use Facebook when they are in the hospital environment?
What if they upload images of other patients and nurses without their knowledge? Is this OK?
12.30pm - Lunch Time and Browse the Book Display
1.30pm - Drilling Down Into The Privacy Act
Privacy and confidentiality concerns and nurses’ duty of care.
How much do you need to know about the legal principles of patient confidentiality and the delivery of professional care?
Nursing handover notes and breaches of privacy.
What do nurses need to do to ensure their documentation is secure?
What do nurses need to know about “Freedom of Information” legislation?
3.00pm - Afternoon Tea and Coffee
3.30pm - National Nurses’ Registration Changes and Professional Documentation
Introduced in July 2010, what does the national nursing regulation require of nurses for documenting their continuing professional development (CPD)?
Specific guidelines and tips.
What is the structure of the new national regulatory authority, under the Australian Health Practitioners’ Registration Act, and why is this information important for you to know?
4.00pm - Close Of Seminar and Evaluations
Allison Willis
Allison is a senior nursing and midwifery policy advisor with some 25 years experience. Until most recently Allison was the Principal Advisor, Professional Practice and Strategic Initiatives with the Nursing and Midwifery Board of South Australia, a position she held for nearly nine years. Prior to that she worked as a Senior Health Care Consultant in the community/ disability sector. Allison has held a ministerial appointment as a member on the Pharmacy Board of South Australia and a Board member and Chairperson on the Shine SA Board. Allison has an extensive background in regulation, governance and professional practice.
In her time at the nmbSA Allison was directly responsible for developing the Standards for Nurse Practitioner Authorisation; Standards for Documentation for Nurses and Midwives; Standards for the Delegation of Care to Unregulated HealthCare Workers and the Scope of Practice Decision Making Framework in South Australia.
Allison is a vibrant and powerful presenter who is consistently highly evaluated by those who attend her educational programs.
