Report Writing in Patient Health Records Course

Report Writing in Patient Health Records Course is organized by Ausmed Education Pty Ltd.

First Published: 03 May 2018
Updated: 12 February 2019
Expires: 03 May 2021

Target Audience:
This Course is relevant to all registered nurses and other health professionals given the critical need for correct documentation to underpin safe practice.

CPD: 1h 40m of CPD

Course Overview:
This Course will provide nurses and midwives with an overview of what is considered to be effective communication through documentation in the patient’s record, and what adverse outcomes can occur when this is done poorly.

Topics:
• The important role of documentation
• The basics of documentation
• Examples of poor versus quality documentation
• Case studies to reinforce your learning

Need:
An essential element of documentation is to provide a record of continuity of care. When documentation is done well the patient’s record also serves as an effective tool of communication amongst the team.

Ocacssionally, records will be needed in a court or tribunal as evidence. As such it is critical for nurses and midwives to understand how these judicial forums will interpret not only what is written in the record but also what is not, and how this may reflect upon them as a health professional and the quality and standard of care they have provided.

Purpose:
The purpose of this Course is to provide registered nurses and other healthcare professionals with principles for effectively communicating patient care in documentation by written words, or other means such as photography/video footage, using examples that have been examined by the Courts.

Learning Outcomes:
• Act on the importance of adequate and accurate documentation to communicate patient information and ensure patient safety
• Use knowledge of judicial interpretation of inadequate documentation to improve your communication in patient care records
• Describe consent requirements for photo/video recordings and how the images are incorporated in the patient's health record to ensure patient rights are protected