Emergency Information


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.