Documentation is a vital part of any health professional’s role. As a student you will be expected to meet documentation standards within patient medical records. The following are some essential elements of written reports that ensure effective communication and fulfil legal requirements:
- Reports to be complete, accurate and legible.
- Reports should be considered and thorough.
- Reports to be written according to the clinician’s level of competence.
- Reports should be objective, factual and avoid judgements.
- Avoid phrases such as “good day”, “appears improved” or “seems depressed”.
- Reports to be confidential.
- Reports to be written in chronological order regarding date and time.
- Reports to be written in blue or black ink.
- All entries to include date, time and to be legibly signed using both name and designation.
- Abbreviations should be used minimally, within the context and within the bounds of the writer’s specialty. Check that the sentence makes sense and that the abbreviations used are well-known and recognised.
- Reports to be continuous – no lines are to be left between reports and any blank spaces that occur should be lined out.
- Person who signs report entry is accountable for entry.
- Reports must never be altered by anyone other than the writer. Any differing opinion is written in progress notes.
- Care Plans are to be updated each shift and where a change to care has or will occur. Additionally Care Plans are also to be reviewed on a regular basis. The timeliness is at the discretion of the professional judgement of allied health/nursing staff providing the care. However if Care Plans are outcome based, some review date should be specified.
Read the Benalla Health Documentation Policy and the Documentation Clinical Practice Guideline.