3. Ethicolegal, Safety and Quality Considerations in Documentation
Nurses and midwives are legally obliged to complete documentation. There is a duty of care to avoid acts or omissions, which could be reasonably foreseen to injure or harm other people. This duty of care means that you must anticipate risks for the people you are caring for and undertake preventive strategies to mitigate this risk. A significant component of this process includes timely and accurate documentation to promote communication for safety.
While quality documentation contributes to improving patient outcomes as it enables communication between members of the multidisciplinary team, it also provides the principal form of evidence for any healthcare-related legal case. Consequently, the importance of quality documentation cannot be underestimated. In this chapter we discuss privacy, confidentiality and the legislation pertaining to documentation.
Clinical Insight
Prior to undertaking a professional experience placement, it is recommended that nursing and midwifery students review the local policies and procedures of the organisation where they are attending placement. However, it is also vital that nursing and midwifery students are also aware of their state/territory’s legislative and regulatory requirements for documentation including being familiar with the appropriate laws that legislate the collection, use, and disclosure of personal health information by health information custodians. Health professionals are bound to comply with these Acts as found in Table 3.
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Location |
Legislation |
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Australia |
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Australian Capital Territory
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New South Wales
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Northern Territory
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Queensland
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South Australia
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Tasmania
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Victoria
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Western Australia
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Personal health information is defined as specific information about an individual in oral or recorded form that relates to physical or mental health, provision of health care (including identifying a provider of health care), a plan of service, donation of body parts or bodily substance, payments or eligibility for healthcare, medicare number. Personal information is kept private. People have a legal right to this privacy, and there are laws that guide health service providers in how information about the health of individuals is collected, recorded, stored, and when and how this information can be used and shared. My Health Record (MHR) is an Australian system of personal health information that can be viewed securely online, from anywhere, at any time. Individuals can choose to share their health information with the health professionals involved in their care. The individual can manage your My Health Record by adding their own information and choosing their privacy and security settings.
Confidentiality ensures people or entities protect another person’s or entity’s information that has been conveyed in confidence and which is not readily available to the public. ‘Medical confidentiality’ obliges a health professional to protect (limit access to) the information discussed in confidence between themselves and a patient or client. There is no specific confidentiality legislation in Australia, so in a strictly legal sense it is governed by ‘common law’. However, there is a commonly understood duty for confidentiality that is found in various professional standards and governance documents. For nurses and midwives, this information is made clear through the NMBA’s key codes and guidelines including the Code of Conduct for Midwives (2018a), the Code of Conduct for Nurses (2018b), The ICN Code of Ethics for Nurses (2021), and the International Confederation of Midwives’ International Code of Ethics for Midwives (2014). Exemptions apply in the case of mandatory reporting (such as notifiable diseases or suspected child abuse) and in the presence of a subpoena as a result of judicial discretion.
Clinical Insight
People’s information can only be disclosed on a need to know basis or in cases of mandatory reporting
Security of information is maintained through the clear guidelines of each hospital or health facility. These policies are based on appropriate legal principles. With the rise of electronic information, mail and communication systems in the healthcare environment, health organisations are focused on maintaining safe and secure systems to preserve the confidentiality of personal health records. Clinical staff are advised how to maintain safe and secure use of electronic information systems in accordance with their employer’s guidelines.
Explanatory Note
When you access an electronic health record, your digital identity/footprint is attached to that record. This means that you should only access records of patients that you are looking after. For example, if you were to access records of family, friends or ‘an interesting case’, and you decided to read the case notes ‘out of interest’ then that EHR will show your name as having accessed the patient’s record. This is a breach of the code of conduct, if you are not directly involved in their care. If the case ended with court proceedings, then you could potentially be called as a witness because your name is linked to the patient’s documentation and therefore it would be assumed that you were involved in their care.
Ownership of healthcare records is held by the healthcare facility where the individual is being treated. It does not belong to the person or an individual health professional (Staunton & Chiarella, 2017). The Office of the Australian Information Commissioner (OAIC) provides useful guidelines in relation to the Freedom on Information Act 1982, which gives individuals the right to request access to government-held information. This right is supported by the Privacy Act (1988) and the subsequent 2014 Australian Privacy Principles. Principle 12 sets out specific details about access to personal information.
