Unit 4 Documentation

Documentation

includes all forms of documentation by a doctor, nurse or allied health professional (physiotherapist, occupational therapist, dietician etc) recorded in a professional capacity in relation to the provision of patient care

Documentation and record keeping

is a fundamental part of clinical practice. It demonstrates the clinician’s accountability and records their professional practice

Documentation

is the basis for communication between health professionals that informs of the care provided, the treatment and care planned and the outcome of that care as a continuous and contemporaneous record

Documentation

is a record of the care and the clinical assessment, professional judgement and critical thinking used by a health professional in the provision of that care

Documentation

should be clear, concise, consecutive, correct, contemporaneous, complete, comprehensive, collaborative, patient-centred and confidential

Documentation

must be patient focused and based on professional observation and assessment that does not have any basis in unfounded conclusions or personal judgements

Clinical staff

must able to competently communicate effectively with individuals and groups using formal and informal channels of communication and ensuring documentation is accurate and maintains confidentiality

Clinical staff

are required to make and keep records of their professional practice in accordance with standards of practice of their profession and organizational policy and procedure

Documentation

is often used to evaluate professional practice as a part of quality assurance mechanisms such as performance reviews, audits and accreditation processes, legislated inspections and critical incident reviews

Documentation systems

should promote appropriate sharing of information amongst the multidisciplinary and teams

Accurate and comprehensive documentation

is a valuable source of data for data coding, health research and a valuable source of evidence and rationale for funding and resource management.

Documentation

should record both the actions taken by clinical staff and the patient’s needs and/or their response to illness and the care they receive

Clinical staff

have legislative, professional and ethical obligations to protect patient confidentiality. This includes maintaining confidential documentation and patient records

Precautions

must be taken to ensure that clinicians are fully informed of appropriate, safe and secure use of electronic information systems and the potential risks involved in using such systems in ensuring and maintain confidentiality

PURPOSE OF GUIDELINES

support employers, policy makers, managers and clinical staff in documentation practices and policies that demonstrate the professional obligation, accountability and legal requirements to communicate patient health information and clinical interventions in the public interest

PROFESSIONAL DOCUMENTATION INCLUDES

Any and all forms of documentation by a clinician recorded in a professional capacity in relation to the provision of patient care

• written and electronic health records,

• audio and video tapes,

• emails and facsimiles,

• images (photographs and diagrams),

• observation charts,

• check lists,

• communication books,

• shift/management reports,

• incident reports and

• clinical anecdotal notes or personal reflections

DOCUMENTATION MUST INCLUDE THE FOLLOWING CONTENT

✓ Problem list, including significant illnesses and medical conditions

✓ Medications

✓ Adverse drug reactions

✓ Allergies

✓ Smoking status

✓ Any history of alcohol use or substance abuse

✓ Biographical or personal data

✓ Pertinent history

✓ Physical exams

✓ Documentation of clinical findings and evaluation for each visit

✓ Laboratory and other studies that signify review by the ordering provider

✓ Working diagnoses consistent with findings and test results

✓ Treatment plans consistent with diagnoses

✓ A date for return visits or a follow-up plan for each encounter ✓ Previous problems addressed in follow-up visits

✓ A current immunization record

✓ Preventive services and risk screening