Clinical Project: Learning Contract on Nursing Documentation

This learning contract project focuses on improving nursing documentation practices within a clinical setting. It begins with a background and rationale highlighting the importance of accurate and legible documentation for effective communication and quality patient care, referencing the NMBA's Code of Professional Conduct. The project utilizes a conceptual reflective framework to identify gaps in practice and knowledge, emphasizing hands-on experience and critical analysis under supervision. Learning objectives include understanding documentation factors, relevant information, electronic medical records (EMR), and maintaining documentation integrity. The project outlines resources such as experienced registered nurses, e-books, and EMR systems. The proposed method involves self-learning, personal evaluation, and practical application, with a detailed timeframe for theoretical knowledge, practical training, reflection, and action planning. The contract aims to enhance the student's ability to provide person-centered care through improved documentation skills.

Running head: LEARNING CONTRACT
Learning Contract
ID Number:
Unit code and title:
Title of Assignment
Name of Unit Co-ordinator:
Due date:
Word count:

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LEARNING CONTRACT
Background and Rationale
Nursing documentation is important for comprehensive clinical communication.
Proper legible documentation provides an appropriate reflection of the nursing assessments,
changes in the conditions and the care provided along with the pertinent information of the
patient in order to provide proper support to the multidisciplinary team in order to procure
quality care evidence of care (Collins et al., 2013). According to the Code of Professional
Conduct for Nurses by the Nursing and the Midwifery Board of Australia (NMBA) (2018),
relevant and clear documentation create provision for the nursing professionals and midwives
in order to stay accountable for their actions.
The rationale behind selection of “documentation” as the main topic of the clinical
project learning contract will help me to increase my knowledge about the basic requirements
of the nursing documentation. It will also help to understand the underlying theory of the
documentation, the documentation fact and how to maintain the integrity of the
documentation. Having a detailed knowledge about the nursing documentation will help me
to upheld quality nursing practice while ensuring person-centred care (Broderick & Coffey,
2013).
Conceptual Reflective Framework
The conceptual reflective framework that will be used in this clinical project contract
learning is highlighted below

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LEARNING CONTRACT
Figure: Model of the Conceptual Reflective Framework
(Source: Nelumbu & Pretorius, 2015)
The process of the reflection will be framed under the clinical situations, in the
clinical wards followed by relftive practice of the procedure and critical analysis in order to
highlight the gaps (Nelumbu & Pretorius, 2015).

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LEARNING CONTRACT
Figure: Different Characteristics of Agents used in Reflective framework
(Source: Nelumbu & Pretorius, 2015)
Nelumbu and Pretorius (2015) are of the opinion that the hands-on experience in the
clinical wards by the nursing professionals help to identify the gaps in practice or the lack of
the proper knowledge in implementation of the nursing professional code of conduct.
Highlighting of the gaps through the use of the reflective practice, under the active
supervision of the registered nursing professionals will help to improve the overall quality of
care.
Learning Objectives
To learn the documentation factors
According to Song et al. (2015) nursing professionals and midwives must avoid the
non-committal documentation like the use of the words “appears” or “seems” as it fail to
reflect factual documentation. Learning proper documentation factors will help the nurse to
avoid error in care plan

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LEARNING CONTRACT
To learn all the relevant information in documentation
Relevant information in the documentation helps in framing proper patient’s handover
or change of shift handover (Song et al., 2015)
To develop the skills of documentation contemporaneously in the electronic medical
records
This skills encourages documentation as soon as possible along with proper
documentation of the date and time (Bruylands et al., 2013)
To learn how to maintain the integrity of documentation
Keeping the personal and other informational details of the patients private and
confidential apart from the members of the multidisciplinary team (Song et al., 2015)
Resource
Human resources
Registered nursing professional: more than five years of experience in the clinical
ward
The nursing professional will help to learn the process of documentation and to
highlight the gaps in practice
Literary resources
E-books related to principle of documentation in nursing practice and the nurse
mentor will select the books (White, L. (2002). Documentation & the nursing process: a
review)

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LEARNING CONTRACT
Other resources
Other resource include from computer system in order to learn the electronic
documentation through Electronic Medical Record (EMR) and Computerized Physician’s
order entry (CPOE). These are technologically advanced process of documentation in nursing
practice.
Proposed method: Self Learning and Personal Evaluation
In order to complete the project I will learn the theories underlying nursing
documentation from the experienced nursing professionals and at the same time will lean the
computerized navigation skills in order to perform electronic documentation in EMR and
CPOE. After gaining knowledge, hands on training will be executed and subsequently
reflected in order to highlight gaps in practice. The mentor nurse will help to highlight gaps
in practice.
Proposed Timeframe
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day
8
Day
9
Day
10
Gaining
theoretical
knowledge of
nursing
documentation
Obtaining
training in
computerized
documentation

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LEARNING CONTRACT
(EMR and
CPOR)
Conducting
practice test
giving
handling
documentation
of patients in
real time
under the
supervision of
registered
nurse
Reflecting on
the clinical
experience
and
highlighting
the gaps
Making action
plans
(SMART
goals) to
overcome
gaps in
practice

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LEARNING CONTRACT
References
Broderick, M. C., & Coffey, A. (2013). Person‐centred care in nursing
documentation. International journal of older people nursing, 8(4), 309-318.
https://doi.org/10.1111/opn.12012
Bruylands, M., Paans, W., Hediger, H., & Müller-Staub, M. (2013). Effects on the quality of
the nursing care process through an educational program and the use of electronic
nursing documentation. International journal of nursing knowledge, 24(3), 163-170.
https://doi.org/10.1111/j.2047-3095.2013.01248.x
Collins, S. A., Cato, K., Albers, D., Scott, K., Stetson, P. D., Bakken, S., & Vawdrey, D. K.
(2013). Relationship between nursing documentation and patients’
mortality. American Journal of Critical Care, 22(4), 306-313.
doi: 10.4037/ajcc2013426
Nelumbu, L. N., & Pretorius, L. (2015). Conceptual framework for facilitating reflective
practice by nurses in the clinical setting. International Journal of Advanced Nursing
Studies, 4(1), 38.
Nursing and the Midwifery Board of Australia. (2018). Professional Codes and Guidelines.
Access date: 28th Feb 2019. Retrieved from:
https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements.aspx
Song, W., Eaton, L. H., Gordon, D. B., Hoyle, C., & Doorenbos, A. Z. (2015). Evaluation of
evidence-based nursing pain management practice. Pain Management Nursing, 16(4),
456-463. https://doi.org/10.1016/j.pmn.2014.09.001
White, L. (2002). Documentation & the nursing process: a review. Cengage Learning.