Documenting and Reporting

Abstract

Effective communication between health professionals is vital to the quality of patient care. Such communication allows a free flow of information between all the members of the inter-professional team and facilitates effective, person-centred care. Generally, health personnel communicate through discussion, reports and records. A discussion is an informal oral consideration of a subject by two or more health care personnel to identify a problem or to establish strategies to resolve a problem. A report is oral, written or computer-based communication intended to convey information to others. For instance, nurses always report on patients at the end of a hospital work shift. A record is written or computer-based. The process of making an entry on a patient record is called recording, charting or documenting. A clinical record, also called a chart or patient record, is a formal, legal document that provides evidence of a patient's care. Although health care organisations use different systems and forms for documentation, all patient records have similar information. Each health care organisation has policies about recording and reporting patient data, and each nurse is accountable for practising according to these standards. Organisations also indicate which nursing assessments and interventions can be recorded by registered nurses and which can be charted by enrolled nurses or by unregulated health care workers. In addition, the Australian Council on Healthcare Standards (ACHS 2010) requires patient record documentation to be timely, complete, accurate, confidential and specific to the individual patient.