Documentation of information

Documentation is an essential component of effective communication. 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. Undocumented or poorly documented information relies on memory and is less likely to be communicated and retained. This can lead to a loss of information, which can result in misdiagnosis and harm.^1,2

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.

Documentation can be paper-based, electronic or a mix of both. It can also take a number of forms, including the care plan, handover notes, checklists, pathology results, operation reports and discharge summaries. 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. For documentation to support the delivery of safe, high-quality care, it should:³

• Be clear, legible, concise, contemporaneous, progressive and accurate

• Include information about assessments, action taken, outcomes, reassessment processes (if necessary), risks, complications and changes

• Meet all necessary medico-legal requirements for documentation.

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. This involves supporting the workforce to document information correctly, and could include policies or training that clearly describe:

• The workforce’s roles, responsibilities and expectations regarding documentation

• When documentation is required

• How to gain access to the healthcare record and templates, checklists or other tools and resources that support best-practice documentation.

Clinical information systems and technologies play an increasingly important role in documentation in the healthcare system. It is essential to consider the safety and quality issues that may arise when designing, implementing or integrating digital health solutions. Any digital health record system that is implemented should meet the elements of best-practice documentation and support effective clinical communication.

This criterion is supported by actions in the Clinical Governance Standard that require organisations to make the healthcare record available to clinicians at the point of care, support the workforce to maintain accurate and complete healthcare records, and integrate multiple information systems if they are used (Action 1.16).

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