This action states

Clinicians document the findings of the screening and clinical assessment processes, including any relevant alerts, in the healthcare record

Intent

Findings of screening and assessment processes are documented accurately and contemporaneously.

Reflective questions

What systems and processes are in place for documenting the findings of screening and assessment processes in the healthcare record?

What processes are used to ensure that, if appropriate, information about the identified risks is shared with all members of the workforce who have contact with the patient?

Key tasks

  • Support clinicians to use organisational and local processes to document the findings of the screening and assessment processes.

  • Involve clinicians in evaluating and improving documentation processes.

Strategies for improvement

Hospitals

This action should align with the requirements of the Communicating for Safety Standard. Work with clinicians to develop processes for documenting the findings of screening and assessment processes. This may include formalising existing processes, and developing or adapting specific paper or electronic tools.

Clinicians require training about organisational processes, as well as more specific training about the use of these processes at the ward, unit or service level. Provide orientation, education and training for clinicians on topics such as:

  • Professional roles, responsibilities and accountabilities in documenting the findings of screening and assessment processes
  • How to use paper or electronic tools to document screening and assessment findings
  • How to document alerts in the healthcare record
  • How to provide feedback about any issues with documentation tools and processes.

Involve clinicians and consumers in reviewing the effectiveness and usefulness of comprehensive care documentation processes. Develop strategies to ensure that updates and changes to relevant tools and processes are effectively communicated to clinicians. This may involve developing specific, targeted implementation strategies to ensure that clinicians understand how to use and apply newly developed processes in their work, and have opportunities to provide feedback about usefulness and effectiveness of these processes.

Day Procedure Services

This action should align with the requirements of the Communicating for Safety Standard. Work with clinicians to develop processes for documenting the findings of screening and assessment processes. In day procedure services, a generic pathway is likely to be appropriate for most patients, with exceptions or individual clinical requirements based on patient risk. This may include formalising existing processes, and developing or adapting specific paper or electronic tools. Ensure that alert processes include the capacity for alerts to be documented during pre-admission screening and assessment.

Clinicians require training about the use of these processes. Provide orientation, education and training for clinicians on topics such as:

  • Professional roles, responsibilities and accountabilities in documenting the findings of screening and assessment processes
  • How to use paper or electronic tools to document screening and assessment findings
  • How to document alerts in the healthcare record
  • How to provide feedback about any issues with documentation tools and processes.

Involve clinicians and consumers in reviewing the effectiveness and usefulness of comprehensive care documentation processes. Develop strategies to ensure that updates and changes to relevant tools and processes are effectively communicated to clinicians. This may involve developing specific, targeted implementation strategies to ensure that clinicians understand how to use and apply newly developed processes in their work, and have opportunities to provide feedback about usefulness and effectiveness of these processes.

Examples of evidence

Select only examples currently in use:

  • Policy documents for recording
    • findings of screening and clinical assessment processes, risks and alerts
    • medical reviews or reassessments and their outcomes
    • changes to the care plan
  • Audit results of healthcare records for the use of a screening and clinical assessment form, and relevant alerts
  • Templates and forms for medical review assessment, risk assessment or care variation
  • Training documents about patient healthcare record documentation, including electronic and paper-based documentation
  • Observation of workforce computer access to healthcare records in clinical areas.

MPS & Small Hospitals

This action should align with the requirements of the Communicating for Safety Standard. Work with clinicians to develop processes for documenting the findings of screening and assessment processes. This may include formalising existing processes, and developing or adapting specific paper or electronic tools.

Clinicians require training about organisational processes, as well as more specific training about the use of these processes for the different services provided. Provide orientation, education and training for clinicians on topics such as:

  • Professional roles, responsibilities and accountabilities in documenting the findings of screening and assessment processes
  • How to use paper or electronic tools to document screening and assessment findings
  • How to document alerts in the healthcare record
  • How to provide feedback about any issues with documentation tools and processes.

Involve clinicians and consumers in reviewing the effectiveness and usefulness of comprehensive care documentation processes. Develop strategies to ensure that updates and changes to relevant tools and processes are effectively communicated to clinicians. This may involve developing specific, targeted implementation strategies to ensure that clinicians understand how to use and apply newly developed processes in their work, and have opportunities to provide feedback about usefulness and effectiveness of these processes.

Hospitals

This action should align with the requirements of the Communicating for Safety Standard. Work with clinicians to develop processes for documenting the findings of screening and assessment processes. This may include formalising existing processes, and developing or adapting specific paper or electronic tools.

Clinicians require training about organisational processes, as well as more specific training about the use of these processes at the ward, unit or service level. Provide orientation, education and training for clinicians on topics such as:

  • Professional roles, responsibilities and accountabilities in documenting the findings of screening and assessment processes
  • How to use paper or electronic tools to document screening and assessment findings
  • How to document alerts in the healthcare record
  • How to provide feedback about any issues with documentation tools and processes.

Involve clinicians and consumers in reviewing the effectiveness and usefulness of comprehensive care documentation processes. Develop strategies to ensure that updates and changes to relevant tools and processes are effectively communicated to clinicians. This may involve developing specific, targeted implementation strategies to ensure that clinicians understand how to use and apply newly developed processes in their work, and have opportunities to provide feedback about usefulness and effectiveness of these processes.

Day Procedure Services

This action should align with the requirements of the Communicating for Safety Standard. Work with clinicians to develop processes for documenting the findings of screening and assessment processes. In day procedure services, a generic pathway is likely to be appropriate for most patients, with exceptions or individual clinical requirements based on patient risk. This may include formalising existing processes, and developing or adapting specific paper or electronic tools. Ensure that alert processes include the capacity for alerts to be documented during pre-admission screening and assessment.

Clinicians require training about the use of these processes. Provide orientation, education and training for clinicians on topics such as:

  • Professional roles, responsibilities and accountabilities in documenting the findings of screening and assessment processes
  • How to use paper or electronic tools to document screening and assessment findings
  • How to document alerts in the healthcare record
  • How to provide feedback about any issues with documentation tools and processes.

Involve clinicians and consumers in reviewing the effectiveness and usefulness of comprehensive care documentation processes. Develop strategies to ensure that updates and changes to relevant tools and processes are effectively communicated to clinicians. This may involve developing specific, targeted implementation strategies to ensure that clinicians understand how to use and apply newly developed processes in their work, and have opportunities to provide feedback about usefulness and effectiveness of these processes.

Examples of evidence

Select only examples currently in use:

  • Policy documents for recording
    • findings of screening and clinical assessment processes, risks and alerts
    • medical reviews or reassessments and their outcomes
    • changes to the care plan
  • Audit results of healthcare records for the use of a screening and clinical assessment form, and relevant alerts
  • Templates and forms for medical review assessment, risk assessment or care variation
  • Training documents about patient healthcare record documentation, including electronic and paper-based documentation
  • Observation of workforce computer access to healthcare records in clinical areas.

MPS & Small Hospitals

This action should align with the requirements of the Communicating for Safety Standard. Work with clinicians to develop processes for documenting the findings of screening and assessment processes. This may include formalising existing processes, and developing or adapting specific paper or electronic tools.

Clinicians require training about organisational processes, as well as more specific training about the use of these processes for the different services provided. Provide orientation, education and training for clinicians on topics such as:

  • Professional roles, responsibilities and accountabilities in documenting the findings of screening and assessment processes
  • How to use paper or electronic tools to document screening and assessment findings
  • How to document alerts in the healthcare record
  • How to provide feedback about any issues with documentation tools and processes.

Involve clinicians and consumers in reviewing the effectiveness and usefulness of comprehensive care documentation processes. Develop strategies to ensure that updates and changes to relevant tools and processes are effectively communicated to clinicians. This may involve developing specific, targeted implementation strategies to ensure that clinicians understand how to use and apply newly developed processes in their work, and have opportunities to provide feedback about usefulness and effectiveness of these processes.