Consists of Comprehensive Clinical Documentation - Nursing Assignment Help

Assignment Task :
 

POLICY STATEMENT

It is the policy of Burnside Hospital (BH) that all patients have a health record that contains accurate, objective, complete and up-to-date clinical documentation that reflects their management, progress and outcomes of care during their hospitalisation.  

Clinical documentation in the patient’s health record provides an essential mode of communication between clinicians involved in the care of the patient.  All clinicians including Nurses, Midwives, Assistants in Midwifery / Nursing, Physiotherapy Aides, Nursing & Midwifery Students, Accredited Visiting Medical Officers (VMO) and Accredited Allied Health Professionals have a legal obligation to ensure that clinical documentation contains an accurate record of the patient’s condition, treatment and responses to care. 

RATIONALE

Comprehensive clinical documentation within a complete health record ensures that a professional standard of documentation is maintained; appropriate care and treatments are provided to the patient; that there is evidence of patient care; and assists the hospital in fulfilling a variety of administrative requirements.

PROCESS

1. The patient’s health record consists of progress notes, Clinical Pathways, charts, diagrams, checklists and a range of unit specific pro forma.  All clinical documentation within the Health  Record must:

• Be objective, comprehensive, logical, legible, clear, and concise

• Be representative of professional observations and assessment

• Be contemporaneous, i.e. made at the time of the event or as soon as practicable, no later than before the end of the shift during which care was delivered.  If a late entry is necessary it should be clearly identified by writing ‘written in retrospect’ at the beginning of the entry;

• Be preceded by a notation of the date and time (using a 24 hour clock) and followed by the author’s signature, printed name, and designation; and written in black pen.

• Be continuous, i.e. no blank spaces between the last entry and the beginning of the next entry.  A line may be drawn along the blank space; and

EXPECTED OUTCOMES

Every patient accessing care at Burnside Hospital will have a complete health record that:

• Consists of comprehensive clinical documentation. 

• Meets external standards and guidelines. 

• Includes an accurate account of assessment, planning, treatment and evaluation of outcomes across the continuum of care.

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