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  • Subject Name : Clinical Nursing

Clinical Documentation in The Patient’s Health Record 

Policy Statement of Burnside Hospital

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. Clinical documentations are actually a methodical records of a patient's clinical history and heed. Meanwhile, It contains the information of patient's health included their recognition details, medical background, clinical examination, and codlings data. Good clinical records include;

1) Appropriate medical conclusion should be taken.

2) The decisions made on the basis of record and procedures taken further decided over and above the behaviour of who made the decisions and procedures.

3) The clinical information of patients should be given to them and must keep their record.

4) Furthermore the evidence of several medicines prescribed and the investigations of treatments should be performed.

In good professional practice along with the delivery of excellence healthcare, clinical record keeping seems to be an essential component. The good clinical records are supposed to facilitate with constant care and it should also developed communication among the diverse professional of healthcare. For this, the clinical records must have to be made up to date by all associates of the multidisciplinary group for instance, physicians, surgeons, nurses, pharmacists, physiotherapists, occupational therapists, psychologists, chaplains, administrators or students that take part in taking care of patients. It is further important that patients must be given the permission to get access to their records so that they get to know about what has already happened and what is going to happen.

Rationale to Clinical Documentation

The precise patient record documentation is to further eminence and stability of concern. It should be created the resources of declaration between members and providers as regards healthiness condition, precautionary health services, management, scheduling and liberation of concern. It should be added that clinical documents ought to be truthful, imitate detailed services being given to a patient and well-timed. Moreover, clinical records is second-hand to assist, facts based healthcare systems decisions, data for lawful records and generate patient registry proceedings consequently a public health agencies be capable of management and investigate hefty patient with great numbers added resourcefully. Particularly, health concern providers exploit clinical documentation in case of billing and coding. In a patient’s clinical documents, some healthcare services take up clinical document improvement specialists to assess apiece patient’s clinical documentation and certain there should be no gaps in comprehensive. Clinical records are sort of helpful documents to assess the excellence of healthcare services.

Appropriately, it seems curtail to write the patient’s record but in present time the government tries to the excellence of the medical record. Documentation of patient’s medical record tells the medical history of patient along with present problems and treatment that is given to the patient. It also aids and estimate which treatment can be given to the patient. The permanent documentation of the medical record of patient also helps for the better care of patient in the future. Moreover, it also builds a file that plays significant role in accessing the efficiency of the treatment give to the patient which can be beneficial for research and educational purpose.

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.

Guiding principle

  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 and logical. Must guarantee medicinal record entries legible.
  • Be representative of professional observations and assessment. Must avoid grasp words or abscond blank spaces.
  • 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; Do not rub out, inscribe over, or se whitener on an entry. Try to avoid inappropriate data you write a discretely dated.
  • Be preceded by a notation of the date and time (using a 24 hour clock) and followed by the author’s signature, printedname, and designation; and written in black pen. Must signify the date and an entry on time.
  • 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
  • Reflect:
  • First hand (direct) knowledge.
  • Evidence of nursing / midwifery assessment (within 8 hours of admission to hospital).
  • VMO documentation regarding patient visits, condition and treatment orders. (This is an essentialcomponent of providing relieving VMO’s with information regarding the patient’s health status).
  • Allied Health Professional documentation regarding patient review, condition and treatment orders.
  • A summary of any incidents / events (aRiskMan incident report must also be completed butreference to the incident report MUST NOT be made in the Health Record)
  • Evidence of planned care.
  • Documentation of variances to the clinical pathway.
  • Evidence of discharge planning and discharge summary.
  • Progressive documentation of the patient’s condition and response to care, i.e. reassessment of the patient’s condition.
    1. If abbreviations and symbols are used in clinical documentation, it is important that their meaning is clearly understood by the health provider using them and / or reading them. To avoid confusion, abbreviations MUSTNOT be used on discharge summaries. Please note that only those abbreviations found on the ‘Approved Metric Terminology, Symbols and Abbreviations’ list (ATTAC-058), are acceptable at BH.
    2. Each item in the health record must have a patient identification label or notation of the patient’s given and surname, date of birth and medical record number.
    3. Do not erase or opaque any documentation error. Draw a single line through the documentation error; write “error” above and initialand date the error.
    4. It is expected that in addition to clinical documentation recorded on the various components of the health record e.g. Clinical Pathways, there will be a nursing or midwifery entry in the progress notes at least every 24 hours but normally each shift. This entry should include an evaluation of the care providedand identification of actual or potential problems / needs. More frequent, ongoing clinical documentation in the progress notes may be indicated if the clinical situation and/or the clinical area dictate it.
    5. All clinical documentation entries in the health record by Assistants in Nursing/Midwifery or Student Nurses must be countersigned by a Registered Nurse / Midwife. Countersigning indicates that the Registered Nurse / Midwife acknowledge their responsibility for any delegated nursing/midwifery care.
    6. On receipt of a referral from the Hospital, other authorised health professionals may be required to access information from and document in the patient’s healthrecord. This may include representatives from the Aged Care Assessment Team (ACAT), pathology and community nursing service providers. 
    7. The collection and storage of clinical information complies with the Privacy Amendment (Enhancing Privacy Protection) Act 2012 which amends the Privacy Act (1988) and the State Records of South Australia General Disposal Schedule No.28.
    8. When documenting information in the health record it is important to note that:
  • The patient has access to their health record through the Australian Privacy Principles as per thePrivacy Amendment (Enhancing Privacy Protection) Act 2012.
  • The health record should not include disparaging or critical remarks about the patient, colleagues or the care / management.
  • The health record is admissible in legal proceedings. In these cases, the individual(s) may not have the opportunity to be present or provide additional clarification of their clinical documentation.
  • References to incident reports, i.e. RiskMan reports, must not be made

Basics Highlights

  • It should be noted that care Phone calls from providers and VMO to be recognized if it impacts on patient.
  • TL passes on VMO order the receiving nurse to document in health record.
  • System approach should be settled ahead and integrated in policy unusual for nursery.
  • Pathology reports to be photocopied and built-in health record to allow for worsening of ink.
  • Customary of documentation to be included in routine performance review.
  • Use of stamps be well thought-out to highlight definite key information in health record.
  • Clinician should be involved in the care and treatment of a patient via electronic means and recommendations.
  • It is added that health care records ought to be available at the point of care or service liberation.
  • The other clinician realistic following consultation in a manner to make sure stability of
    care for patients.
  • In patient safety staff should be involve in the analysis of complaints, review activities and to ethics committee approval if required.
  • It should be noted that healthcares involved in urgent public health investigation for protecting population health,
    with relevant legislation.
  • The authorised agent services based on a case accord with health examine liberate of data the policies and confidentiality laws.
  • An experienced healthcare is able to recognise the facts and suggest the patient a suitable clinical strategies.

Expected Outcomes of Clinical Documentation

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.

The documentation will show clear evidence of care given, that appropriate assessment, decision making and implementation of required care has occurred and an evaluation of this has taken place.

Evaluation of Clinical Documentation

Understandable and brief documentation of record is important to give patient excellence care, guarantee precise and on time payment for the services provided, ensuring accurate and timely payment for the services furnish, justifying mismanagement hazards, and accessing the word of healthcare providers and plan the treatment of patient and uphold the scale of care.

Patient Health Records will be regularly audited by the Health Information Manager and Clinical Managers (or their delegates). Audit results will be used for benchmarking against previous performance and external standards and guidelines. Audit results will be reported to the relevant Burnside Hospital committees and area managers for the purpose of ongoing evaluation and improvement of clinical documentation in the health record. 

Associated Burnside Hospital Documents

Approved Metric Terminology, Symbols and Abbreviations ATTAC-058

Development of Clinical PathwaysPOL-015

Incident Management Policy POL-062

Privacy PolicyPOL-103

Application for Access to Personal Records FRM-125

Acknowledgement of the receipt of Personal Health Records FRM-124

Authority to Exchange Information FRM-228

Release of Patient Information Guidelines GUID-027

Privacy Statement – Patient Information Leaflet (as attached)

Offsite Storage Procedure PRC-254

Medical Records Forms Management POL-163

Nursing / Midwifery Clinical Pathways (available on Fast Track)

Accredited Practitioner By-LawsRES-054

References for Clinical Documentation

Australian Commission for Safety and Quality on Health Care; National Safety and Quality Health Service (NSQHS) Standards. Standard 1 - Governance for Safety & Quality in Healthcare. October 2012

Australian Council on Healthcare Standards, EQuIPNational Standard 14 – Information Management 2012

Australian Nursing & Midwifery Council (2010): National Competency Standards for the Registered Nurse.

Privacy Act 1988

Privacy Amendment (Enhancing Privacy Protection) Act 2012

State Records of South Australia General Disposal Schedule No. 28 – Clinical & Client-Related Records of Public Health Units in South Australia (effective from 19 August 2014 to June 30 2025)

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