10h 15m CPDSeminar

Nursing Report Writing and Documentation Seminar

Two-Day Seminar for All Nurses

Details

Adelaide
11 - 12 May 2020
The Lakes Resort Hotel Adelaide
141 Brebner Drive
West Lakes SA5021

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Price

$559.00
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Why Attend

If you did not write it – did it even happen? Attend this seminar and refresh your documentation skills. This seminar includes:

  • Are you documenting correctly?
  • How do your perceptions and attitudes influence your approach to documentation?
  • What are the care issues that underpin what you write?
  • How do patient preferences, clinical reasoning and evidence relate to your documentation?
  • How can you see documentation as a tool to get you someplace better?

Attend this seminar to gain confidence in your practice. Book now!

Need for Program

Good communication is vital in healthcare. What and how you communicate inpatient records can impact on their outcomes and reflects on professional standards. Communicating about patients within the health team is bound by standards of practice, legal requirements, as well as policies and procedures across a range of media. Nurses must be constantly vigilant in relation to professional documentation that is within legal requirements and best practice in record-keeping.

Purpose of Program

This seminar is an essential update on documentation across all media for the provision of safe and quality care.

Your Learning Outcomes

  1. Apply principles of documentation and data recording within a healthcare context in accordance with the relevant standards and legal requirements
  2. Construct a concise trail of evidence and documentation about a person in your care, including your actions and how they improve patient outcomes
  3. Demonstrate record writing of high-risk incidents and situations that is objective and factual
  4. Optimise interprofessional collaboration through communication to enhance patient care outcomes
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Schedule

Day One


8:30am - Registration and Refreshments


9:00am

Record Writing and Documentation: Reflecting Standards of Care

Documentation offers a clear picture of the progress – or lack of progress – of a patient’s condition. It is a vital communication tool. The quality and accuracy of report writing and patient documentation are used to interpret the standard of care provided. This introductory session reviews:

  • What contribution does competent documentation make to nursing care?
  • Can poor documentation imply poor care?
  • Why is timely documentation important?
  • What is the impact of failing to record information in patient notes?

10:00am

The Pitfalls of Poor Documentation

Record writing and documentation is not only a legal but also an ethical, regulatory and professional practice issue for all nurses. This session looks at the severe consequences of poor record writing. It includes:

  • How is a written record used as evidence?
  • Why are records and documents so highly regarded at law?
  • How can proper documentation assist you to avoid 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, and why does this matter?

11:00am - Morning Tea


11:30am

Basics of Report Writing

Refreshing the basics of documentation helps build your confidence and avoid worry. This session offers practical hints and tips to ensure that your documentation provides an accurate record, as well as effective communication. It looks at:

  • The 20 dos and don’ts of documentation
  • How to correct errors
  • Tips for ensuring the information you are recording is correct
  • Recognising false entries

12:30pm

Examples of Quality v Poor Report Writing

In this session before lunch, as a group we will compare recent examples of poor v quality document. Examples of complete and correct nursing reports will be included alongside erroneous examples. Discussion includes:

  • Why were some nursing reports complete and correct?
  • How are other examples fraught with issues?
  • What can we learn from the coroner’s recommendations?

1:30pm - Lunch and Networking


2:30pm

Continuity of Care and Communication

Interdisciplinary communication that includes multiple health professionals relies on quality report writing. This session will examine:

  • How poor communication and record writing can affect the continuity of care
  • Issues when multiple entrants are writing in patient health records

3:15pm - Afternoon Tea


3:30pm

Photo and Video Documentation: More than Just Taking a Snap!

Photography is a modern aspect of clinical record keeping. What are the legal and ethical obligations of the person documenting using images and video? This session explores:

  • How and when should photos and videos be recorded?
  • Can a person refuse consent?
  • What about the storage and sharing of images?
  • Are there policies for the use of photo and video documentation?

4:15pm - Close of Day One of Seminar

Day Two


9:00am - Commencement of Day Two


9:00am

Reporting Incidents and Other ‘High Risk’ Situations

When an incident or high-risk situation occurs, documentation and record writing is particularly important. The importance of ensuring that records are objective and factual accounts is vital. This session will demonstrate complete documentation when the following scenarios arise:

  • Scenario 1 - Reporting an adverse patient outcome
  • Scenario 2 - Documenting a change in a person’s mental health
  • Scenario 3 - Reporting poor Conduct
  • Scenario 4 - Documenting an incident as a witness

10:30am - Morning Tea


11:00am

Clinical Pathways and Care Plans

Documenting in care plans or in standardised clinical pathway presents a different challenge to writing case notes in patient records. This session looks at:

  • Why can documentation by exception be problematic?
  • How do you know if a clinical pathway is current?
  • What if care falls outside of a standardised pathway?
  • How should variances be recorded?
  • How do you individualise care plans?

11:45am

Electronic Health Records: Benefits and Burdens

Benefits of Electronic Health Records (EHR) include improved efficiency and access. Despite this, there is still a threat to the privacy and security of data if protocols are not adhered to. This session will explore:

  • What recordkeeping risks are associated with EHR?
  • How can privacy breaches occur?
  • Why is avoiding unapproved abbreviations essential?

12:30pm - Lunch and Networking


1:30pm

Recording Outside of Patient Notes

From time to time, healthcare staff will be required to complete additional documentation to what is recorded in patient case notes. This session provides guidance for recording these scenarios. It includes:

  • What is expected when documenting in a communication book?
  • How can discharge plans, letters and referrals be written correctly?
  • What is the importance of clear advance care directives in documentation?
  • What needs to be included when recording telephone calls?
  • What about email communication?

2:30pm - Afternoon Tea and Coffee


3:15pm

Case Studies to Practice Correct and Complete Documentation

In this final session, your presenter will invite you to practice your own record writing. Using case scenarios and as a group, you will be asked to prepare an entry in a patient’s case notes. It includes:

  • An opportunity to apply your learning and consolidate your knowledge of accurate and complete record writing

4:00pm - Close of Seminar and Evaluations


educator image

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. Read More

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Nursing Report Writing and Documentation Seminar
West Lakes