Confidentiality and Documentation
In a rural setting such as this, it is not uncommon to encounter acquaintances amongst the patient population. Always remember you are bound by privacy laws and strict confidentiality must be maintained. We ask that you please read and sign the NHW confidentiality agreement contained in this pack.
Preprinted handover sheets are provided in the acute/sub acute wards for the purpose of providing patient diagnosis and doctor; these can be found in the handover rooms. They must be placed in the shredder bin at the end of the day to protect patient privacy. Wards will also have white boards located in the nurse’s stations if you need to locate specific patients.
Please read and print out the attached Privacy Confidentiality and Security Agreement and sign and bring it with you on orientation day.
 NHW Confidentiality Agreement | type: pdf | size: 39 kB |
Documentation
Documentation is a vital part of any health professional’s role. As a student you will be expected to participate in the documentation within patient medical records in a variety of ways applicable to your discipline. The following are some essential elements of written reports that ensure effective communication and fulfil legal requirements.- Reports to be complete, accurate and legible.
- Reports should be considered and thorough.
- Reports to be written from the level of a clinicians level of competence.
- Reports should be objective, factual and avoid judgements.
- Avoid phrases such as “good day”, “appears improved” or “seems depressed”.
- Reports to be confidential.
- Reports to be written in chronological order as to date and time.
- Reports to be written in blue or black ink.
- All entries to include date, time and to be legibly signed using both name and designation.
- Only accepted Organisations abbreviations to be used. The only acceptable abbreviations allowed are those appearing in the ‘The Australian Dictionary of Clinical Abbreviations, Acronyms and Symbols’ 4th Edition. Published by HIMAA. A copy of this book is available on each ward
- Report is to be continuous – no lines are to be left between reports and any blank spaces that occur to be lined out.
- Person who signs report entry is accountable for entry.
- Reports must never be altered by anyone other than the writer. Any differing opinion is written in progress notes.
- Care Plans are to be updated where a change to care has or will occur. Additionally Care Plans are also to be reviewed on a regular basis. The timeliness is at the discretion of the professional judgement of allied health/nursing staff providing the care. However if care plans are outcome based some review date should be specified.