Recording Clinical Care

Aims: The aims of this programme are to assist nurses to understand their duty of care and responsibility in the area of best practice in documentation of clinical care.

Course Content: Introduction to best practice in documenting clinical care, continuity of care, individualised, up to date, factual and unambiguous approach, legibility, signatures and dates, timely documentation in chronological order, timed entries, abbreviations, accepted grading systems, errors, referrals and consultations, maintenance and storage of records, patient identification, instruction and supervision of students in documentation. Code of Professional Conduct for each Nurse and Midwife, Scope of Practice and other key Policies and documents that underpin best practice in recording clinical care.  Legal issues in documentation.

Objectives: To provide nurses with best practice guidelines in recording clinical care.

Target Audience: All nurses who wish to update their knowledge in documentation and recording clinical care.