Guidelines on Documentation and Electronic

ELECTRONIC DOCUMENTATION
Student’s name;
Course unit;
Institutional affiliation;
Honorary lecturer;
Date of submission;

Nursing documentation calls in for responsibility and accountability of the registered nurse or
midwife. Responsibility in nursing is the nursing duties, roles or tasks performance obligation.
Nursing duty performance requires nurse’s sound professional judgement and being in a position
of being answerable for the decisions made in performing the duties. A registered nurse or
midwife is said to be accountable with his/her actions when he is capable of giving an account of
his/her judgements actions and omissions that occur while performing the nursing care.
Documentation as a way of promoting effective nursing management through effective
communication as captured by the Nursing and Midwifery board of Australia nurses’ code of
conduct, when done effectively It makes nurses’ accountability possible. this shows how
communication in healthcare is paramount and of importance. The written documentation
outlines the nurse’ cares and the evaluations done by the nurses. Ove the years, the tremendous
increase in information and technology has made it possible for many healthcare centers to adopt
the digital format of written communication. This electronic written information ensures that
person’s health status and required therapeutic interventions are made known to all members of
the healthcare team concerned with the patient. There can at times be concerns of registered
nurses where their accountability and completion of documentation is less than required. The
paper has therefore analyzed concerns in relation to completed communication and
accountability from the roles of healthcare professionals and electronic documentation related to
the case: Inquest into the death of Tray Almond.
Electronic communication and Accountability of the registered nurse
The Nurses together with the other healthcare professionals taking care of a patient in a
healthcare facility are responsible for not only producing the client’s care records inform of
wither paper or electronic but also maintaining the records. It is considered a mechanism that

allows effective communication between the healthcare team members, effective monitoring and
evaluation of the patient’s condition outcome and progress and retaining health information
integrity over a given period of time. However, at times the healthcare record can be produced as
an evidence in legal proceedings if by any case it is necessary. At such situations of a healthcare
record having a potential of being admitted into evidence there is need for comprehensive
documentation that is also accurate and of high quality. Critical high-quality documentation is
possible when documentation meets the following four requirements. Document fact, document
all relevant information, document contemporaneously and maintaining the documentation
integrity. A relevant clear and accurate documentation is essential and makes a registered nurse
accountable for the care they provided, a principle that is highly enriched by the Code of
Professional Conduct for Nurses in Australia under the third principle of cultural practice and
respectful relationships outlined by the Domain; Practice safely, effectively and collaboratively.
The Document fact as the first electronic documentation guideline involves the nurse
documenting what he/she saw, heard or did for the patient in term of the patient’s care and the
condition. Such a guideline guides the registered nurse from avoiding non- committal
documentation such as use of words that don’t bring the reflection of factual documentation.
Instead it proposes that the healthcare records should be recorded objectively by registered
nurses should record. It gives a warning for recording objective or emotive information.
The second guideline allows the registered nurse to document all the relevant information
concerning the patient. the documentation, and should be with respect to the total current
condition of the patient and not just on a clinical specialty view. Any changes observed as the
care continues should as well be documented. Besides it gives an outline that nurse should also
consider documenting any actions or treatments and their respective effects to the patient’s