9:00am - Commencement of Day Two
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
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?
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
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
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