If you did not write it – did it even happen? Attend this seminar and refresh your documentation skills. This seminar includes:
Attend this seminar to gain confidence in your practice. Book now!
8:30am - Registration and Refreshments
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:
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:
11:00am - Morning Tea
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:
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:
1:30pm - Lunch and Networking
Interdisciplinary communication that includes multiple health professionals relies on quality report writing. This session will examine:
3:15pm - Afternoon Tea
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:
4:15pm - Close of Day One of Seminar
9:00am - Commencement of Day Two
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:
10:30am - Morning Tea
Documenting in care plans or in standardised clinical pathway presents a different challenge to writing case notes in patient records. This session looks at:
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:
12:30pm - Lunch and Networking
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:
2:30pm - Afternoon Tea and Coffee
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:
4:00pm - Close of Seminar and Evaluations
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.
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.
This seminar is an essential update on documentation across all media for the provision of safe and quality care.
10 - 11 May 2021
17 - 18 May 2021
21 - 22 Jun 2021
Events held in September onwards are scheduled to proceed. We hope to see you at an Ausmed Event soon!