Class notes
Communication and Documentation
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Provides a summarised collection of notes, tools and lists in relation to good communication and documentation required to be undertaken by a student nurse.
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COMMUNICATION AND DOCUMENTATIONCommunication is defined as imparting or exchanging information,
thoughts or ideas using speech, writing or some other mediums such as
signals or behaviour.
We use communication to:
Convey info.
Request info.
Give social acknowledgement.
TYPES OF COMMUNICATION
VERBAL
NON-VERBAL (Body Language)
WRITTEN
VISUAL (Body language)
Good record keeping is a VITAL part of effective communication in nursing
and integral to promoting safety and continuity of care for patients and
clients.
Nursing staff need to be CLEAR about their responsibilities for record
keeping in whatever format records are kept.
Record keeping is IMPORTANT because it provides LEGAL and
PROFFESIONAL responsibility, validates care given, continuity of care and
maintains patient safety.
KEY PRINCIPLES
Records must be kept AT the time of SOON as possible after the
event.
Records must be SIGNED, TIMED and DATED.
(If digital) Records must be TRACEABLE to the person providing care.
Records must be completed ACCURATELY.
Records must avoid jargon and speculation.
(If alternation is needed) original records must be visible – draw a
line through the original – signed and dated.
Records must be UP TO DATE on electronic systems.
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