This CPD site is for UK health professionals
Cover image for: Report Writing in Patient Health Records
Badge from the American Nurses Credentialing Center showing that Ausmed is an accredited provider with distinction

The Ausmed Education Learning Centre is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. Provider number is P0342.

CPD1h 40m of CPD
Total Rating(s)621
First Published
Updated12 February 2019
Expires03 May 2021
Recorded InMelbourne, Australia

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.

  • The important role of documentation
  • The basics of documentation
  • Examples of poor versus quality documentation
  • Case studies to reinforce your learning

An essential element of documentation is to provide a record of continuity of care. When documentation is done well the patient’s record also serves as an effective tool of communication amongst the team.

Ocacssionally, records will be needed in a court or tribunal as evidence. 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 provided.


The purpose of this Course is to provide registered 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.

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
Target Audience

This Course is relevant to all registered nurses and other health professionals given the critical need for correct documentation to underpin safe practice.


No conflict of interest exists for anyone in the position to control content for this activity. Wherever possible, generic or non-proprietary names of medications or products have been used.


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Linda Starr Visit

Dr Linda Starr has undergraduate and postgraduate qualifications in general, mental health nursing, law, education and a PhD in legal issues in elder abuse. Linda has extensive experience as an RN in metropolitan and rural locations, in general nursing, mental health, forensic health, aged care, and management. She has held senior positions in academia including the Dean of the School of Nursing and Midwifery. Linda has publications in health law and forensic health issues. Linda is an associate professor in the College of Nursing and Health Sciences at Flinders University and a consultant educator in health law and ethics for nurses, midwives and carers. She is Chair of the SA Board of Nursing and Midwifery, Fellow of the College of Nursing Australia, Foundation President of the Australian Forensic Nurses Association, Member on the School of Health Academic Advisory Board for Open Colleges and the International member on the Editorial Board for the Journal of Forensic Nursing.

Learner Reviews

621 Total Rating(s)
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Kathy Pettet
13 Sep 2019

Thoroughly enjoyed the course, fabulous presentation, and would highly recommend this course to reiterate the importance documentation, and your legal responsibilities in the role of a registered nurse.

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Laura Laura
11 Sep 2019

This was an excellent course and very relevant to the legal parameters that apply to nursing documentation.

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Natalie Barnes
10 Sep 2019

Good refresher on what, how and when to document in patient notes.

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Trevor Mason
07 Sep 2019

The presenter is obviously well versed in this subject. She presents it well and her manner certainly kept my attention. Certainly recommended.

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narelle windle
02 Sep 2019

Great review and enforces what is the right thing to do

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Sandra Dufourq
02 Sep 2019

Thorough information

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Gonda van Baarsen
31 Aug 2019

Very interesting case studies

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Lynley Macleod
31 Aug 2019

thorough and enjoyable learning experience

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Pamela Boyd
31 Aug 2019

Excellent resource with much helpful information to assist us in providing continuity of care and reminding us to use objective formats - SOAP, SBAR. Good reminder that a lack of information is care not given. Our documentation must be accurate, complete, contemporaneous, it provides continuity of care for our patient and defends ourselves.

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Silvana Leiss
31 Aug 2019