THE FUTURE OF Nursing

Nursing Documentation & Legal Implications 

- Training by Institute of Health and Nursing Australia 

In a nutshell, this video is about some of the examples of good documentation, how to document, and essential elements of documentation, why we document, some of the basic laws regarding documentation, looking at documentation from a legal point of view, and "the mead model” of documentation. 09:00 - Healthcare documentation should be ◾️ legible, ◾️ objective, ◾️ clear, ◾️ concise, ◾️ client-centered, ◾️ confidential, ◾️ evidence, ◾️ continuity, and ◾️ critical and integral to practice. 15:05 - All forms of documentation recorded by authorized health professionals including: ◾️ written printed and electronic health records ◾️ audio and video tapes, ◾️ emails, faxes, images observation charts ◾️ checklists, ◾️ communication books, ◾️ shift management reports, ◾️ incident reports, ◾️ anecdotal notes, ◾️ personal reflection 22:00 - Purpose of documentation ◾️ To reflect quality and continuity in care ◾️ To reflect current AHC standards and guidelines ◾️ Client-centered care tool ◾️ Effective communication between the multidisciplinary healthcare team members ◾️ Accountability by health care professionals ◾️ Professional responsibility ◾️ Legislative requirement - permanent and legal record reflecting AHC standards & guidelines ◾️ Quality research ◾️ Resource management 24:11 - Understanding basic laws of documentation ◾️ Permanent and legal record ◾️ Information about the client & care management ◾️ In compliance with the Australian Health Care Standards accreditation ◾️ Recorded interventions by the multidisciplinary team ◾️ Record of laboratory and diagnostic reports ◾️ Accountability by healthcare professional ◾️ Provide evidence of care 24:30 - Common Nursing Documentation ◾️ Admission & Nursing history ◾️ Graphic charts & flow sheets ◾️ Acuity charting or ICU/HDU observation systems ◾️ Standardized care plans ◾️ Critical pathways ◾️ Patient progress notes ◾️ Discharge summary and transfer forms ◾️ Short-term health care documents (e.g.: day procedure) ◾️ Long-term (e.g.: aged care, rehabilitation, palliative care) 26:20 - Reporting & recording patient information ◾️ Reporting may be written or verbal ◾️ Doctors may get/give a verbal report on patient progress or condition over the telephone ◾️ Interventions or treatment changes over the phone, verbal, or written. ◾️ Verbal orders or charges to care must be documented in the patient's notes by the nurse (e.g: ‘as per RMO, HMO, VMO orders) 26:45 - Quality Documentation It is guided by the following: - ◾️ Factual: Must be objective descriptive information concerning the patient. ◾️ Accurate: Information recorded must be accurate and clear with measurements or descriptions. ◾️ Complete: Information should be concise and thorough about patient care. ◾️ Current: Date & time are essential and critical to documentation. ◾️ Organized: Information should be recorded in an organized or logical manner 28:50 - Mead Model ◾️ Organized in a systems approach ◾️ The patient is at the center of all the activities ◾️ Emphasis is on the physical aspects of the patient in an assessment ◾️ An anatomical approach to assessing and making clinical judgments ◾️ Most used framework in nursing documentation 30:10 - Rules for charting ◾️ Chart everything ◾️ Do not chart subjective opinions ◾️ Be accurate ◾️ Do not obliterate an entry 37:55 - Ongoing charting and report changes ◾️ Chart as you go ◾️ If observer changes in the patients do not just chart them, but also notify the physician 38:40 - Correct after last entry – no charting for others ◾️ If you make a mistake in charting – correct it after the last entry you made-not where you should have made it in the first place ◾️ If you are asked to chart for someone else don’t do it 

Australian Nursing and Midwifery Federation

Nursing and Midwifery Board - Ahpra

The Future of Nursing