It is continuous and nursing documentation should reflect this.Īt the beginning of each shift, a ‘shift assessment’ is completed as outlined in the Nursing documentation is aligned with the ‘nursing process’ and reflects the principles of assessment, planning, implementation and evaluation. There is an expectation that shift required documentation is completed within 3 hours of shift start time. National Safety & Quality Health Service Standards. On admission and at the commencement of each shift, all ‘required documentation’ must be completed to comply with the Required documentation: minimum documentation required to reflect safe patient care.Real time: nursing documentation entered in a timely manner throughout the shift.EMR Review: process of working through the EMR activities to collect pertinent patient details.This will ensure consistent clinical communication processes across the RCH. To provide a structured and standardised approach to nursing documentation for inpatients.
TIMELY MANNER MEANING PROFESSIONAL
Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice. Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care. Nursing documentation is essential for good clinical communication. Note: This guideline is currently under review.
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