Speakers - WNSC 2023

Abstract

Nursing documentation is essential for good clinical communication.

Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care.Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice

Documentation is considered as a vital communication tool among healthcare professionals. Quality nursing documentation plays a vital role in the delivery of quality nursing care services

The aim of the presentation is to explain the need to  provide a structured and standardised approach to nursing documentation for inpatients and to ensure consistent clinical communication processes .The main required documentation are ,minimum documentation required to reflect safe patient care,on admission and at the commencement of each shift,all ‘required documentation’ must be completed to comply with the National Safety & Quality Health Service Standards,There is an expectation that shift required documentation is completed within 3 hours of shift start time.Documentation is essential for quality nursing care aswell for patient safety. Nurses need to focus on the documentation process to make it sufficient and relevant.