Nursing Documentation and CPD

Writing Nursing Notes Correctly and Preparing your Record of CPD

10 Hours | 30 Mins
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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.

In addition there will be extensive information on CPD, how this relates to your practice and your mandatory obligations under the law.

Need for Program

As digital technologies increasingly alter the manner in which nurses document their care, new risks emerge. These risks include the potential for inadvertent ‘broadcasting’ of documentation relating to the work a nurse does. As well, the regulation of nursing is becoming more stringent and requires nurses to be far more conversant with high standards of documentation. This includes the recording of mandatory CPD. There is a need for education that enables nurses to review the nature of their professional documentation requirements across the scope of their practice.

Aims of Program

This program aims to review key principles of nursing documentation and to consider the major legal implications that are emerging, particularly in the use of electronic devices for documenting patient care. A further aim is to thoroughly enlighten nurses about what constitutes CPD and how this relates to mandatory obligations for practicing as a nurse.

Learning Objectives

At the conclusion of this program it is expected that the participants will be able to:

  1. Explain the purpose and function of nursing documentation
  2. Construct a clear and concise report about a patient whose condition has deteriorated and the nursing actions that occurred as a result of your intervention
  3. Analyse the difference between a gap, a need and a want for CPD education and explain their significance.
  4. Correctly document how selected CPD relates to your context of practice and produce a report for auditing purposes


Day One

8:30am - Registration and Refreshments


The Invisible Nurse – Without Documentation Your Work is Anecdotal

If you didn’t write it down then it didn’t happen! Accurate nursing observations when translated into concise 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 and provides significant advantages if things go wrong
  • The use of effective written communication skills to convey information accurately yet concisely
  • Ethical considerations

10:30am - Morning Tea and Coffee


Setting Benchmarks for Nursing Documentation

What underpins good nursing documentation? Examining the significance of grammar and expression as foundation stones for high quality written communications this session will answer the following questions:

  • What are the best ways to ensure your documentation is of the highest standard?
  • Why this document and not that one?
  • What benchmarks can you use to determine how frequently your documentation should be completed?
  • Who else in the team should document and what are the ramifications of this (including documentation by non-professional staff)?
  • What is the implication of signing your documented practice?

Practice Session: Engage with colleagues to write a patient care activity and then critically analyse your documentation.

12:00pm - Lunch Break and Networking


Be Careful What You Write – A Cautionary Note for Nurses!

This session looks at some common pitfalls and traps of nursing documentation and shows how they may have severe consequences.

  • Why are records and documents so highly regarded at law?
  • A review of the risks associated with poor nursing documentation
  • How can documentation assist you to avoid legal jeopardy, such as accusations of negligence and malpractice?
  • What happens to your documentation if it becomes part of a legal case?
  • How long is your documentation retained by a health agency?

2:30pm - Afternoon Tea and Coffee


Nurses, Facebook and other Social Media – Beware!

A look at some of the pitfalls of social media for health professionals, including texting and taking photos with mobile phones whilst at work.

  • Why has the Nursing and Midwifery Board warned nurses about using Social Media?
  • What do nurses need to be wary of when posting on Facebook and other social media sites?

4:15pm - Close of Day One of Program

Day Two

9:00am - Commencement of Day Two

Continuing Professional Development (CPD)
There have recently been some major changes in the regulation of nurses, which have profound implications for every registered nurse. The onus of responsibility for proving competence to practice lies firmly with you, which means you must have correct documentation in place to demonstrate the rationale behind your selection and use of CPD. Today’s program will thoroughly explain the rationale behind CPD, why you need to take it very seriously and plan your education accordingly.


Protecting your Registration and CPD

This session will explain the framework within which you practice and the reason why the term ‘Nurse’ is a legally protected word. It will look at:

  • The structure of the new national regulatory authority under the Australian Health Practitioners’ Registration Act, and the reasons it has introduced requirements for mandatory CPD
  • What nurses need to know to ensure they comply with the rules for their license to practice


Mandatory Requirements for CPD

  • What does the national nursing regulation mean for nurses and their CPD?
  • Requirements for mandatory CPD?
  • Specific guidelines and tips

10:30am - Morning Tea and Coffee


What Evidence Should I Provide for my CPD?

  • What evidence does the Board require to show completion of CPD?
  • What type of education qualifies as CPD?
  • How to select unbiased, high-quality and relevant CPD
  • What are the long-term professional implications of including CPD that is specific to your current employment (e.g. orientation, non-transferable policy development) in your portfolio?

12:00pm - Lunch Break and Networking


How Do I Self-assess Against the ANMC Competency Standards?

A practical session to refresh your knowledge of the Competency Standards and, how to undertake a self-assessment of competence. This session will set you in good stead to determine your CPD goals and develop your learning plan.


Context of Practice and Identifying the Need for Education

CPD hours should be carefully used to develop you professionally, now and in the long term, and it is essential that you select your CPD carefully. The first step is to establish what education you need to improve your practice. This short session will help you do this, looking at:

  • Why is the establishment of need for CPD so important to your future career?
  • What is the difference between:
    • The GAP in my knowledge
    • The NEED I have for specific education (to competently practice)
    • Versus the education I WANT to do?

2:30pm - Afternoon Tea and Coffee


Where to Document my CPD?

  • What is required to be included in a Professional Portfolio?
  • What are the advantages of documenting my CPD online and how will this assist me in the future?
  • How many years do I need to retain this documentation for?


How to Document CPD

A step-by-step guide through the process of developing your Learning Plan and matching it to your NEED for the education, evaluating the education and correlating it to future CPD.



In this session you will document how you identified the gap in your knowledge, wrote the need for this education, planned your activity and evaluated the outcomes.

4:00pm - Reflection

4:15pm - Close of Seminar and Evaluations



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