Documentation in nursing and midwifery: Australian edition

Abstract

Documentation is a permanent record of all transactions of care. It includes every form that is completed in relation to the care of the person. Collectively, these forms make available the formal, legal evidence of care provided to the person while they are seeking health care. Documentation also enables communication within the healthcare team. The information recorded in the documentation record is used to improve the continuity of care provided to the person while also assisting in informing the team’s decisions about the person’s current care needs. Effective documentation within the health record can therefore assist the health professional to provide person-centred care. Documentation also enhances patient safety as it is a mechanism to communicate assessment findings and decisions made by and within the multidisciplinary team. The accurate and timely documentation forms an important component of a healthcare facility’s ability to meet the National Safety and Quality Health Service Communicating for Safety Standard (Australian Commission on Safety and Quality in Health Care [ACSQHC], 2021). By documenting, the healthcare team are able to communicate and track the progress or decline in a person’s condition over time. The tracking of the person’s condition is achieved through recording various assessment findings for the person, relaying the desired treatment plan for the person’s current condition, and noting how the person has responded to the implementation of this plan of care. Such information is collected on numerous charts/forms such as those used to record the person’s vital signs and fluid balance. Table 1 provides examples of these different document types