2. Indications for Documentation
Documentation is an essential part of healthcare provision in Australia. Documentation is used as a tool to: enhance intra- and inter-professional communication; improve patient safety: improve the quality of healthcare provision (e.g., through risk minimisation and management, education and research purposes); meet the needs of the activity based funding system in Australia; and finally, as a legal requirement. Table 2 provides additional information about how documentation is used in health care.
|Communication, continuity of care, and clinical judgement||Documentation communicates clinical information about a person including data related to their current state of health and illness. The documentation record is therefore a vehicle of communication within the multidisciplinary healthcare team. By each member of the healthcare team documenting their assessment findings, the plan of care for the person and the outcomes associated with the care provided with, and to, the person is coordinated and connected. That is, continuity of care is better enabled. Additionally, the documented data allows for health professionals to incorporate this information into their clinical judgement and decision-making about the future care needs for the person.|
|Patient safety||Linked with communication, documentation can assist with patient safety. Patient safety involves partnering with other health professionals and recipients to prevent and minimise unsafe acts, reduce harm, and respond accordingly to potential hazards (ACSQHC, 2021). Actions to achieve patient safety involve providing timely, clear, and comprehensive documentation. In doing so, a common understanding about the person is promoted amongst the multidisciplinary team which in turn promotes more effective decision-making about the person’s emerging care needs. Documentation can include directives and care plans related to patient safety, such as the use of falls and allergy alerts.|
|Quality improvement||Quality improvement involves constant reflection and commitment to working toward the best outcomes associated with healthcare systems that are safe, effective, person-centred, timely, efficient, fiscally responsible, and equitable. Chart audits and reviews (e.g. hand hygiene audits) aid with the evaluation of healthcare provision and compliance with professional standards such as the National Safety and Quality Health Service Standards (ACSQHC, 2021). These quality improvement initiatives can help identify necessary changes in practice and foster evidence-informed approaches to care. For example, a quality improvement study could reveal high rates of incident reports related to falls. The study findings could then prompt the organisation to introduce additional educational sessions about falls prevention.|
||Documentation records can influence state and federal funding for healthcare delivery. For example, Australian public hospitals are funded using activity based funding whereby hospitals receive funding based on the volume and level of complexity of the patients they treat. It is therefore essential that health professionals (and organisations) maintain clear and comprehensive records of the care and services provided so that each episode of care is assigned the correct Australian Refined Diagnosis Related Group (AR-DRG).|
||In addition to supporting high-quality and safe patient care, it is important to consider the legal aspects of documentation. The health record is a legal document that provides evidence of the assessments conducted on the person and the care and services provided. The health record may be subpoenaed for proceedings related to cases such as negligent practice, coroner’s inquests, violence, child welfare, and criminal offences. These proceedings may take place many years after you have cared for the person, therefore, the health professional is somewhat reliant on their documentation to recall the situation being investigated. Consequently, a health professional’s documentation must be clear, accurate, and reflective of the assessment that was performed and the care provided. It may be useful to remember the saying: “If it’s not documented, it wasn’t done” (i.e., your documentation must be complete, or it will be presumed that care was not provided).|
||Nurses, midwives and other health professionals sometimes review documentation records as part of their research. For example, they may examine factors (e.g., patient satisfaction, health outcomes) related to nurse-sensitive indicators/outcomes. For example, a research project might focus on the impact nurse ratios has on morbidity and mortality rates in a particular unit, or it may analyse documentation notes to assess how nurse-led discharge planning after surgery corresponds to the rates of hospital readmission in a certain population group.|
|Population and public health insights
|A review of health records can provide insight into specific populations and public health issues. For example, reviews of health records can help health professionals track data and identify trends across patient groups or organisations. These reviews may provide information related to the transmission of diseases and epidemics, the effectiveness of interventions, or complications associated with certain locations or demographic groups. For example, influenza-related hospital admission rates and mortality rates are recorded and tracked each year.|
|Risk Assessments||The NSQHS standard covering implementation of comprehensive care highlights that to provide person-centred care it is essential to perform regular assessments (on admission and at the beginning and throughout each nursing shift). An element of this assessment is performing risk assessments (such as assessing for the person’s risk for falls or developing a pressure injury). The type of risk assessments undertaken with the person is dependent on several factors including the person’s characteristics (e.g., their presenting problem, age, or comorbidities), their treatment pathway, and each facility’s policies and procedures.|
Documentation is critically important in cases that involve violence because the health record may be used as a source of evidence in legal proceedings. Therefore, nurses and midwives must clearly and comprehensively document their detailed assessment. It is important that you incorporate direct quotes from the person and place them in quotation marks, even if they are expletives (swearing). Photographic images are also necessary to document cases of physical and sexual violence. In cases of bruising, swelling, lacerations, and/or contusions, use a measurement tool as a point of reference. Consult your organisational policies about photography and record-keeping, including guidelines related to designated devices for recording images and how the person is identified in the picture.
Nursing informatics refers to processing, storing, and retrieving documented data to optimise healthcare delivery and improve patient outcomes. It is an evolving speciality that uses familiarity with nursing’s front line role in a clinical setting combined with an understanding of clinical processes and workflow to maximise data and technology in daily nursing practice.