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Documentation
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 (please tick each point as you read them):
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 GSHS Documentation Policy, and the Common Abbreviations for Students
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