InformedConsentforTreatment-ACHG：治疗知情同意-achg.docVIP

Client Record Documentation in Community Health VHA Clinical Governance in Community Health Discussion Paper March 2009 Aim The aim of this paper is to present a set of recommended procedures for client record documentation in community health for discussion by the sector. Background Appropriate client record documentation is integral to quality practice as it provides a record of professional practice and is the basis for communication between health professionals. The VHA Clinical Governance in Community Health project aims to strengthen client record documentation practice through the following recommended documentation practices and processes. Definition Client record documentation includes: ‘all forms of documentation recorded by a service provider in a professional capacity in relation to the provision of client care’ Modified from WHO, 2007 This documentation may include written and electronic health records, audio and video tapes, emails, facsimiles, images (photographs and diagrams), observation charts, check lists, communication books, shift/management reports, incident reports and clinical anecdotal notes or personal reflections (held by the clinicians personally) or any other type or form of documentation pertaining to the care provided. Legislation Victorian Health Records Act 2001 Victorian Health Service Act 1988 Victorian Information Privacy Act 2000 The Rationale A uniform approach to client record documentation needs to be developed in the sector to address the following: A review of complaint and insurance cases highlight the need to improve documentation. More than 80% of claims against healthcare professional are difficult to defend because records are inadequate, missing or ambiguous (Guildwatch). Inadequate records imply inadequate care. Failure to record examinations, test results and treatment can be interpreted that these processes where not completed. File audit results from community health services indicate there is room for improvem