An important part of clinical communication is the exchange of information about a person’s care that occurs between treating health professionals.
Structured, clear, and continuous communication facilitates continuity of care by all members of the care team and contributes to better patient outcomes by enabling information exchange.
Communication within an organisation acknowledges that an organisation will have procedures and information channels in place that support care across the organisation and the requirements of auditing and accreditation.
At all times the confidentiality and privacy of information and patients should be considered.
Respecting a person’s privacy will be part of a nurse’s interactions with patients, carers and families; with the care team; and across the organisation. This can include:
Digital Health Australia provides guidance for health care professionals and organisations to use My Health Record safely and responsibly.
Information about a person’s care is communicated through clinical documentation or clinical records. These may be on paper, electronic or a combination.
These documents include
For complex patients, the list of minimum documentation requirements for safe care includes:
allergies and adverse drug reactions
Use any acronyms and abbreviations consistently and use standardised terminology in written records.
Note your organisation’s policy on documentation.
Being succinct in presenting potential changes to a care plan can help especially in a busy work environment. Use dot points backed up with supporting evidence.
Visit ACSQHC - Documentation of information
Documentation of information (862kb pdf)
There are tools that can help with standardised documentation practice.
This information was drawn from the following resources:
Page created 23 September 2022