Will your Documentation Stand up in Court ?
By Clinical Quality Facilitator , Claire Cherrill .
Gail Bingham , General Manager Governance and Quality , Louise Fowler , Clinical Nurse Specialist Aged Residential Care , Sue Stevens , SupportNet , Andrea Davis , Clinical Auditor and myself recently took Aged Care Providers and Tauranga Hospital staff through a ‘ mock ’ scenario of what it might be like to stand before a Court to defend nursing practice .
While the scenario was delivered in a light hearted manner , and the participants were encouraged to speak freely and candidly about the information presented to them , the message was clear – poor decision making and inadequate documentation can lead to serious consequences for the Registered Nurse , Health Care Assistant and more importantly the resident / patient .
Role playing a mock court case scenario was a fun way to deliver a very important message , and I did have fun .
The workshop was interactive . Participants discussed their knowledge of delegation , effective communication and record keeping , and I believe we achieved that . Our staff do have the knowledge and understanding of best practice ; with their questions and feedback during the 2 hour session demonstrating this .
The workshop was attended by approximately 75 staff representing 15 Aged Care facilities , Aged Care community workers and Tauranga Hospital staff .
Feedback was positive . Nurses from Aspen Lifecare Limited said the workshop highlighted their responsibilities in an educative manner without being dictatorial . Awesome acting , dreadful hair styling !”
Malyon House Resthome & Hospital Clinical Manager , Ricki Smith said , " In patient care facilities and organisations , proper and accurate documentation has always been important , but in today ’ s shifting healthcare environment , it has become even more of a strategic imperative than we have ever known . Documentation is critical for patient care , not only because it validates the care we have provided but protects us in this increasingly litigious society . We all have the same constant issue , that nurses are extremely busy and are at high risk of not connecting the dots
Louise Fowler and Sue Stevens act out a scene in a mock court case .
in our documentation . What this session has reminded us of is the impact of poor documentation and what may not seem an issue at the time , can in fact snow ball unveiling a raft of short comings . It was a fantastically unconventional education session which highlighted the daily struggles nurses face of depleted time , documentation and delegation ."
• The Registered Nurse and Health Care Assistant are answerable for decisions made and actions taken . Delegation should only happen after a decision making process has occurred .
• Poor documentation can lead to untimely and inappropriate interventions .
• Effective communication is essential .
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