Course Overview


This Course will provide nurses and midwives with an overview of what is considered to be effective communication through documentation in the patient’s record, and what adverse outcomes can occur when this is done poorly.

Learning Outcomes

  • Act on the importance of adequate and accurate documentation to communicate patient information and ensure patient safety
  • Use knowledge of judicial interpretation of inadequate documentation to improve your communication in patient care records
  • Describe consent requirements for photo/video recordings and how the images are incorporated in the patient's health record to ensure patient rights are protected

Topics include:

  • The important role of documentation
  • The basics of documentation
  • Case studies
  • Poor versus quality documentation

Target audience

Primarily nurses and midwives working in any clinical setting, whether this is in acute care, aged care, in the community, or with vulnerable populations within any health care setting. However, other health professionals and those working in management and education will also find this information valuable.


Provide nurses and other healthcare professionals with principles for effectively communicating patient care in documentation by written words, or other means such as photography/video footage, using examples that have been examined by the Courts.


Perhaps the most important role of documentation is to provide a record of continuity of care. In today’s healthcare system, patients are likely to have a range of health professionals providing different aspects of their care. When documentation is done well the patient’s record also serves as an effective tool of communication amongst the team. However, from time-to-time the patient’s record will be needed in a court or tribunal as evidence in coronial inquiries, criminal or civil matters, or tribunal hearings. Furthermore, poor documentation can serve as in indication for the need for a performance review of the practitioner. As such it is critical for nurses and midwives to understand how these judicial forums will interpret not only what is written in the record but also what is not, and how this may reflect upon them as a health professional and the quality and standard of care they have delivered.

Health professionals in Australia that are registered with AHPRA are required to obtain continuing professional development (CPD) hours/points each year that relates to their context of practice, in order to comply with mandatory regulatory requirements.