Clinical Documentation: Getting it Right
Welcome to the eLearning module Clinical Documentation - Getting it Right.
This course comprises two learning resources. The resources collectively address the importance and requirements for quality clinical documentation in the provision of quality healthcare. The first resource challenges clinicians to reflect on why accurate and timely documentation is essential to best practice. The second resource provides a guide to best practice clinical documentation.
A certificate is issued on completion.
On completion of this training, you will be able to:
- describe why quality patient records are important to the patient, colleagues, cares teams and healthcare organisations.
- identify the risks posed by poor documentations: to patients and clients, individual staff and organisations.
- write appropriate content in the patient record (eMR or paper) following the 6Cs: complete, correct, clear, client / patient centred, contemporaneous, and collaborative
- write in the patient record using appropriate language style and word choices.
- write contemporaneously and collaboratively.
This course is applicable to all clinical staff and contractors. This course may qualify for up to 0.5 hrs of Continuous Professional Development.