Effective Documentation for CMs and RNs

Learning Outcomes

By the end of this webinar, you will be able to:

• Describe legislative and legal considerations regarding documentation in-home care
• Outline the regulatory requirements regarding documentation (Aged Care Quality Standards and NDIS Practice Standards)
• Describe the principles of effective documentation
• Select and apply the key recognised documentation methodology ISBAR, SOAP & DAP for documentation
• Describe the style of documentation required for the Aged Care Quality Standards in relation to referrals, reporting, mutual obligation, and other purposes
• Develop outcome-based documentation that supports consumer choice, independence, and quality of life
• Identify key aspects of documentation through case studies
• Summarise considerations in relation to documentation including:
  • Electronic records
  • Streamlining documentation without sacrificing accuracy
  • Documenting using objective methods
  • Consumer rights and safety
  • Managing confidentiality and privacy of records
  • Documenting special situations
  • Common documentation errors and terminology to avoid
  • Contemporaneous recording of clinical information
  • Documentation that enables monitoring of quality of care