Report Writing in Patient Health Records

Course Overview

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.

Topics

• The important role of documentation
• The basics of documentation
• Examples of poor versus quality documentation
• Case studies to reinforce your learning

Need

An essential element of documentation is to provide a record of continuity of care. When documentation is done well the patient’s record also serves as an effective tool of communication amongst the team.

Ocacssionally, records will be needed in a court or tribunal as evidence. 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 provided.

Purpose

The purpose of this Course is to provide registered 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.

Learning Outcomes

• Act on the importance of adequate and accurate documentation to communicate patient information and ensure patient safety
• Use knowledge of judicial interpretation of inadequate documentation to improve your communication in patient care records
• 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

Target Audience

This Course is relevant to all registered nurses and other health professionals given the critical need for correct documentation to underpin safe practice.

Disclosure

No conflict of interest exists for anyone in the position to control content for this activity. Wherever possible, generic or non-proprietary names of medications or products have been used.

Educator

Linda Starr

Dr Linda Starr has undergraduate and postgraduate qualifications in general, mental health nursing, law, education and a PhD in legal issues in elder abuse. Linda has extensive experience as an RN in metropolitan and rural locations, in general nursing, mental health, forensic health, aged care and management. She has held senior positions in academia, including the dean of the School of Nursing and Midwifery. Linda has publications in health law and forensic health issues. Linda is an associate professor in the College of Nursing and Health Sciences at Flinders University and a consultant educator in health law and ethics for nurses, midwives and carers. She is chair of the SA Board of Nursing and Midwifery, fellow of the College of Nursing Australia, foundation president of the Australian Forensic Nurses Association, member on the School of Health Academic Advisory Board for Open Colleges and the international member on the Editorial Board for the Journal of Forensic Nursing. See Educator Profile