Are You Using the Correct Language in Your Documentation?

4m of CPD
With the advent of the digital hospital, every word we write about our patients is potentially searchable in an indelible trail of communication. Codes of conduct target use of the mediums through which we communicate. Ironically, we probably have less control than ever on where our words end up.

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With the advent of e-health and the digital hospital, every word we write about our patients is potentially searchable in an indelible trail of communication. Codes of conduct often target use of the mediums through which we communicate, yet ironically we probably have less control than ever on where our words end up. Just like our selfies. Instead, focus on the words on the screen and page, and what they say about your attitudes and personal interactions.

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Meet the educator

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Andrew Blythe
Andrew Blythe is a writer and editor who has a Masters of Writing, Editing and Publishing from the University of Queensland. In addition, he is an adjunct research fellow at Griffith University within the School of Human Services and Social Work, assisting the school with both curriculum review, and lived-experience research development. He enjoys communication in all its forms and has prepared and presented material via print, including as former editor of Time and Place (the Queensland Heritage Council magazine) and Queensland Pride, as well as radio, television and multimedia formats. He is currently writing a memoir about his father’s experience of receiving a heart transplant, as well as documenting other peoples’ experiences of the Queensland health system.
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What do others think?

184 reviews by Ausmed Learners
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Tintumol Mathew
27 Jul 2020
Good read
Samandeep Ahluwalia
25 Apr 2020
Debra Curran
29 Aug 2021
Very interesting article to read, very well written and gave me food for thought, as I looked up the references and I learned a lot of new acronyms that ought not ever be used in patients/clients notes as is is vitally important to only ever create respectful notes on clients/patients There is a reference about patients who are comfortable with acknowledging their sexuality, and that health staff can use neutral relationship terms like ‘partner’ or ‘spouse’, as opposed to the heteronormative ‘husband’ and ‘wife. I am more than happy to go with this ; however I do find it very insulting and disturbing to be directed to now not document husband or wife and only ever refer to them as partners, as this is truly offensive to a great deal of especially older persons who regard themselves as husbands and wives and many have done so for many years and to these people to be a husband or a wife is an important title and ought be replaced by partner or spouse. Bottom Line = We need to be respectful to all persons.
Portrait of Mikal Debabe
Mikal Debabe
07 Jun 2021
Julia Taylor
20 Mar 2022
Excellent information to help in documentation
01 May 2022
Registered Nurse
Good to help in record documentation..
Portrait of Sharina Hussain
Sharina Hussain
27 Aug 2021
Useful resource for correct documentation.
Anne Thorpe
15 Sep 2021
Handy reminder of the need for clarity in documentation
Sukhjit Kaur
22 Feb 2021
I got more knowledge qnd gained my skill
Losena Vulatolu
24 Jun 2021
Important of communicating clear and understanding each other point view to a particular situations or a clients.
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