Action 6.11

Consider and comply with relevant state and territory policies on documentation requirements in relation to clinical information.

Develop policies and processes that encourage a shared understanding of the organisation’s documentation requirements. These could outline:

• When documentation is required
• What needs to be documented (that is, critical information, risks, reassessment processes and outcomes, and changes to the care plan)
• What format of documentation is required
• Expectations regarding information being recorded (that is, contemporaneous, accurate, legible and up to date)
• Where information should be documented, and how to gain access to and use the organisation’s information management systems
• Roles and responsibilities relating to documentation.

The following ‘CARE’ elements¹ provide a useful guide when considering what good written documentation may look like in practice. They apply equally to digital information.

Compliant and complete

• All electronic and written documentation adheres to the standards and procedures of the health services and professional bodies concerned; this includes the use of approved abbreviations, and rules for clinician and patient identification
• Documentation is complete and current (for example, new or emerging information is recorded, daily progress notes or care plans are documented, a discharge summary is completed at the time of discharge)
• Clinicians provide the right documents and use them correctly.

Accessible and accurate

• Paper and electronic documents are available to clinicians who need them, when they need them, and are in language that the intended readership can easily understand
• Relevant, up-to-date information is immediately at hand and easy to locate, or searchable (physical accessibility)
• The documents consider the potential future relationship and the needs and the capabilities of those who will use the information (deferred accessibility); clinicians should not use language that excludes the people who will be using the information (such as the patient, carers, families and other clinicians across disciplines)
• The information recorded correctly reflects the event being documented.

Readable

• Documents are legible and can be understood; electronic and paper forms and checklists should provide enough space so that they can be completed accurately and legibly, and include clear instructions about how they should be completed
• Acronyms and abbreviations are avoided (in both design and completion) if there is any potential for ambiguity
• Documents are as specific as possible.

Enduring

• Documents are materially durable, not loose paper that is likely to slip out or fade
• The meaning of the documents is maintained, and they are completed in such a way that someone who is not present at the time of the recording can interpret the information – written information restricts the immediacy of feedback, so predict the reader’s need to know, and try to anticipate their queries by providing enough information and justification to explain recommendations and instructions (actions to be taken and why), rather than just listing them.²

Implement standardised and structured templates, checklists or forms that are based on best practice and developed in collaboration with clinicians, to support documentation of clinical information.¹ Ensure that the workforce has easy access to these resources, and training about documentation protocols and how to use any standardised forms.

For electronic discharge summaries, core information components are specified by the Australian Digital Health Agency. The Commission’s National Guidelines for On-Screen Presentation of Discharge Summaries provides recommendations about the best on-screen view of a discharge summary and other strategies to deal with presentation inconsistencies.

If electronic health systems are implemented to support documentation (for example, digital healthcare records, information-sharing systems, electronic patient journey boards), consider requirements under the Clinical Governance Standard (particularly Actions 1.16, 1.17 and 1.18), and actions related to managing risks for clinical communication (Action 6.1), and monitoring and reporting incidents (Action 1.11).

Consider and comply with relevant state and territory policies on documentation requirements in relation to clinical information.

Develop policies and processes that encourage a shared understanding of the organisation’s documentation requirements. These could outline:

• When documentation is required
• What needs to be documented (that is, information from pre-admission screening, alerts, risks, medical reviews, reassessment processes and outcomes, and changes to the care plan or pathway)
• What format of documentation is required
• Expectations regarding information being recorded (that is, contemporaneous, accurate, legible and up to date)
• Where information should be documented, and how to gain access to and use the organisation’s information management systems
• Roles and responsibilities relating to documentation
• Processes for transferring information relevant to patient care, including critical information, between clinicians responsible for care, both internally and externally.

The following ‘CARE’ elements¹ provide a useful guide when considering what good written documentation may look like in practice. They apply equally to digital information.

Compliant and complete

• All electronic and written documentation adheres to the standards and procedures of the health services and professional bodies concerned; this includes the use of approved abbreviations, and rules for clinician and patient identification
• Documentation is complete and current (for example, new or emerging information is recorded, daily progress notes or care plans are documented, a discharge summary is completed on discharge)
• Clinicians provide the right documents and use them correctly.

Accessible and accurate

• Paper and electronic documents are available to clinicians who need them, when they need them, and in a language that the intended readership can easily understand
• Relevant, up-to-date information is immediately at hand and easy to locate or searchable (physical accessibility)
• The documents consider the needs and capabilities of those who will use the information (deferred accessibility); clinicians should not use language that excludes the people who will be using the information (such as the patient, carers, families and other clinicians across disciplines)
• The information recorded correctly reflects the event being documented.

Readable

• Documents are legible and can be understood; electronic and paper forms and checklists should provide enough space so that they can be completed accurately and legibly, and include clear instructions about how they should be completed
• Acronyms and abbreviations are avoided (in both design and completion) if there is any potential for ambiguity
• Documents are as specific as possible.

Enduring

• Documents are materially durable, not loose paper that is likely to slip out or fade
• The meaning of the documents is maintained, and they are completed in such a way that someone who is not present at the time of the recording can interpret the information – written information restricts the immediacy of feedback, so predict the reader’s need to know, and try to anticipate their queries by providing enough information and justification to explain recommendations and instructions (actions to be taken and why), rather than just listing them.²

Implement standardised and structured templates, checklists or forms that are based on best practice and developed in collaboration with clinicians, to support documentation of clinical information.¹ Ensure that the workforce has easy access to these resources, and training about documentation protocols and how to use any standardised forms.

For electronic discharge summaries, core information components are specified by the Australian Digital Health Agency. The Commission’s National Guidelines for On-Screen Presentation of Discharge Summaries provides recommendations about the best on-screen view of a discharge summary and other strategies to deal with presentation inconsistencies.

If electronic health systems are implemented to support documentation (for example, digital healthcare records, information-sharing systems, electronic patient journey boards), consider requirements under the Clinical Governance Standard (particularly Actions 1.16, 1.17 and 1.18), and actions related to managing risks for clinical communication (Action 6.1), and monitoring and reporting incidents (Action 1.11).

Examples of evidence

Select only examples currently in use:

• Integrated patient healthcare record, either electronic or paper based, with capacity to incorporate information from multiple sources
• Information management system that
  • includes care pathways and risk alerts as key components
  • provides reports for monitoring patient care
• Policy documents about the information management system that specify the time frames and formats for documenting
  • critical information, alerts and risks
  • any medical reviews or reassessments and their outcomes
  • changes to the care plan
• Standardised templates, such as medical review assessment forms, comprehensive risk assessment forms and care variation forms, for documenting in the healthcare record critical information and the actions taken
• Observation that the workforce has computer access to healthcare records in clinical areas
• Audit results of healthcare records for evidence of updated care plans, reassessments and alerts
• Training documents about the information management system.

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established documentation processes.

Small hospitals that are not part of a local health network or private hospital group should:

• Develop and implement systems to support the contemporaneous documentation of critical information in the healthcare record, and ensure that they comply with relevant state and territory policies on documentation requirements about clinical information
• Record the organisation’s documentation policies, and make them available to the workforce
• Communicate to the workforce their roles and responsibilities for documentation.

Develop policies and processes that encourage a shared understanding of the organisation’s documentation requirements. These could outline:

• When documentation is required
• What needs to be documented (that is, critical information, risks, reassessment processes and outcomes, and changes to the care plan)
• What format of documentation is required
• Expectations regarding information being recorded (that is, contemporaneous, accurate, legible and up to date)
• Where information should be documented, and how to gain access to and use the organisation’s information management systems
• Roles and responsibilities relating to documentation.

The following ‘CARE’ elements¹ provide a useful guide when considering what good written documentation may look like in practice. They apply equally to digital information.

Compliant and complete

• All electronic and written documentation adheres to the standards and procedures of the health services and professional bodies concerned; this includes the use of approved abbreviations, and rules for clinician and patient identification
• Documentation is complete and current (for example, new or emerging information is recorded, daily progress notes or care plans are documented, a discharge summary is completed on discharge)
• Clinicians provide the right documents and use them correctly.

Accessible and accurate

• Paper and electronic documents are available to clinicians who need them, when they need them, and in a language that the intended readership can easily understand
• Relevant, up-to-date information is immediately at hand and easy to locate, or searchable (physical accessibility)
• The documents consider the potential future relationship and the needs and capabilities of those who will use the information (deferred accessibility); clinicians should not use language that excludes the people who will be using the information (such as the patient, carers, families and other clinicians across disciplines)
• The information recorded correctly reflects the event being documented.

Readable

• Documents are legible and can be understood; electronic and paper forms and checklists should provide enough space so that they can be completed accurately and legibly, and include clear instructions about how they should be completed
• Acronyms and abbreviations are avoided (in both design and completion) if there is any potential for ambiguity
• Documents are as specific as possible.

Enduring

• Documents are materially durable, not loose paper that is likely to slip out or fade
• The meaning of the documents is maintained, and they are completed in such a way that someone who is not present at the time of the recording can interpret the information – written information restricts the immediacy of feedback, so predict the reader’s need to know, and try to anticipate their queries by providing enough information and justification to explain recommendations and instructions (actions to be taken and why), rather than just listing them.²

Implement standardised and structured templates, checklists or forms that are based on best practice and developed in collaboration with clinicians, to support documentation of clinical information.¹ Ensure that the workforce has easy access to these resources, and training about documentation protocols and how to use any standardised forms.

For electronic discharge summaries, core information components are specified by the Australian Digital Health Agency. The Commission’s National Guidelines for On-Screen Presentation of Discharge Summaries provides recommendations about the best on-screen view of a discharge summary and other strategies to deal with presentation inconsistencies.

If electronic health systems are implemented to support documentation (for example, digital healthcare records, information-sharing systems, electronic patient journey boards), consider requirements under the Clinical Governance Standard (particularly Actions 1.16, 1.17 and 1.18), and actions related to managing risks for clinical communication (Action 6.1), and monitoring and reporting incidents (Action 1.11).