![]() The workforce’s roles, responsibilities and expectations regarding documentation This involves supporting the workforce to document information correctly, and could include policies or training that clearly describe: Regardless of who records information in the healthcare record, organisations need to ensure that their systems and processes for documentation meet the requirements of this standard. Meet all necessary medico-legal requirements for documentation. ![]() Include information about assessments, action taken, outcomes, reassessment processes (if necessary), risks, complications and changes For documentation to support the delivery of safe, high-quality care, it should: 3īe clear, legible, concise, contemporaneous, progressive and accurate For this criterion, organisations are required to have in place systems to ensure that essential information about a person’s care is documented in the healthcare record. It can also take a number of forms, including the care plan, handover notes, checklists, pathology results, operation reports and discharge summaries. The intent of this criterion is to ensure that relevant, accurate, complete and up-to-date information about a patient’s care is documented, and clinicians have access to the right information to make safe clinical decisions and to deliver safe, high-quality care.ĭocumentation can be paper-based, electronic or a mix of both. This can lead to a loss of information, which can result in misdiagnosis and harm. Undocumented or poorly documented information relies on memory and is less likely to be communicated and retained. Given the complexity of health care and the fluidity of clinical teams, healthcare records are one of the most important information sources available to clinicians. Aged Care Quality Standards – Clinical Careĭocumentation is an essential component of effective communication.Diagnostic Imaging Accreditation Scheme Standards.National Safety and Quality Digital Mental Health Standards.National Clinical Trials Governance Framework.National Safety and Quality Primary and Community Healthcare Standards.Recognising and Responding to Acute Deterioration Standard.Correct identification and procedure matching.Clinical governance and quality improvement to support effective communication. ![]()
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