Medical Documentation

Medical documentation is an integral part of practice to ensure safe and effective care. Documentation is a record of the care provided by a health care provider; and is a primary communication between health professionals.

Comprehensive and complete record - clinical staff have a professional obligation to maintain documentation clear, concise and comprehensive as an accurate and true record of care.

Patient centred and collaborative - documentation should be centred to the specific needs of the patient.

Ensure and maintain confidentiality - this includes maintaining patient confidentiality, in all care settings. Clinicians have legislative, professional and ethical obligations to protect patient confidentiality. That information shared