Accurate Documentation Flashcards Preview

MIDW127 - Beginning the Journey > Accurate Documentation > Flashcards

Flashcards in Accurate Documentation Deck (11):
1

Documentation

- 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

2

Documentation is...

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

3

Documentation Standards

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

4

FACTUAL - Focused on the client

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

5

FACTUAL - Accurate

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.

6

FACTUAL - Complete

Must include all relevant information

7

FACTUAL - Timely

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

8

FACTUAL - Understandable

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

9

FACTUAL - Always Objective

Must be based on clear, unbiased statements

10

FACTUAL - Legible

Must be easy to read and decipherable with correct abbreviations

11

Tips

- 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