Accurate Documentation

Question 1

Documentation

Answer 1

• Documentation can make or break the defence of a hospital or staff if legal action is instigated
• Australia has one of the highest incidences of medical litigation in the developed world
• Litigation can be initiated many years after a critical event
• Memories fade - accurate documentation is crucial

Question 2

Documentation is…

Answer 2

Any health record relating to the care of the woman, baby, family or community group

Question 3

Documentation Standards

Answer 3

F - Focused on the client
A - Accurate
C - Complete
T - Timely
U - Understandable
A - Always Objective
L - Legible

Question 4

FACTUAL - Focused on the client

Answer 4

Must be personalised to reflect the client’s needs, values and rights and their involvement in care decisions

Question 5

FACTUAL - Accurate

Answer 5

Must give a true and clear picture of the client’s perspective of their health and wellbeing, the plan of care, the care provided and the effects of that care.

Question 6

FACTUAL - Complete

Answer 6

Must include all relevant information

Question 7

FACTUAL - Timely

Answer 7

All significant events must be recorded as soon as possible so that the record reflects the client’s current status

Question 8

FACTUAL - Understandable

Answer 8

Must be written in plain language and if abbreviations or symbols are used they must be well understood

Question 9

FACTUAL - Always Objective

Answer 9

Must be based on clear, unbiased statements

Question 10

FACTUAL - Legible

Answer 10

Must be easy to read and decipherable with correct abbreviations

Question 11

Tips

Answer 11

• Record client comments, identifies subjective data but use “” quotation marks
• Be accurate when recording times/information
• Must include all relevant information, how often and how much influenced by employer policy and complexity of client needs and changing status
• When recording information about an exchange of information or referral clearly identify them by name
• Must record all significant events as soon as possible
• Minimise abbreviations, plain language, correct spelling
• No value judgements, avoid vague phrases
• Legible - if you make an error do not use whiteout. Rule through and sign errors
• Know the exact meaning of the terminology you use
• Check you have the right chart/patient ID on every page
• Sign
• Begin each entry with date, time (24hr) and speciality
• Write legibly in black ink
• Use care plans, partograms, clinical pathways as adjuncts to progress notes - avoid duplication
• Distinguish between what you observe and what is related to you by another