Nursing Documentation and CPD - Improving Your Quality and Safety
- : Surry Hills NSW 2010
Includes: Protecting Your Income; Documenting Safely; Communicating with Confidence; Planning Your Next Career Move and much, much more …
The aim of this seminar is to revise key principles of nursing documentation and to discuss major legal implications and contemporary issues relating to what and where nurses write, such as the use of electronic devices for documenting patient care. The theme of accountability reflected in documentation responsibilities will be examined throughout this program.
In addition there will be extensive information on CPD, how this relates to your practice and your mandatory obligations under the law.
Need for Program
As digital technologies increasingly alter the manner in which nurses document their care, new risks emerge. These risks include the potential for inadvertent ‘broadcasting’ of documentation relating to the work a nurse does. As well, the regulation of nursing is becoming more stringent and requires nurses to be far more conversant with high standards of documentation. This includes the recording of mandatory CPD. There is a need for education that enables nurses to review the nature of their professional documentation requirements across the scope of their practice.
Purpose of Program
This program aims to review key principles of nursing documentation and to consider the major legal implications that are emerging, particularly in the use of electronic devices for documenting patient care. A further aim is to thoroughly enlighten nurses about what constitutes CPD and how this relates to mandatory obligations for practicing as a nurse.
At the conclusion of this program it is expected that the participants will be able to:
- Explain the purpose and function of nursing documentation
- Construct a clear and concise report on a patient whose condition has deteriorated and the nursing actions that occurred as a result of your intervention
- Analyse the difference between a gap, a need and a want for CPD education and explain their significance
- Correctly document how selected CPD relates to your context of practice and produce a report for auditing purposes.
- Schedule Day One
8:30am - Registration and Refreshments
9:00amNurse Documentation - Your Professional ‘Footprint’
This introductory session sets the scene for this seminar by reflecting on the factors changing the governance environment of all health professionals. It includes the impact that evidence and new knowledge is having on the regulation of nurses. Includes:
- What’s happening in healthcare and why does accountability matter so much?
- What are the roles of the different agencies which impact on what a nurse can and/or should do?
- What AHPRA means to you - the Australian Health Practitioners Regulation Agency (AHPRA)
- What are the roles of the Nursing and Midwifery Board of Australia (NMBA) and nursing associations such as the State Nurses' Association and others?
9:45amUnder Scrutiny from All Angles - PINs, Pages, Phones and Surveillance
Without realising it, many nurses work in an environment in which their every action is traceable, or recorded. How can you safeguard your practice in this type of environment? Includes:
- Are you under video surveillance in your workplace corridors or car parks and what are the implications of this?
- Are you photographed dispensing S4 & S8 drugs from the DD cupboard?
- Who else can document notes under your name?
- Anonymous notices in the tea room ... what they really say
10:30am - Morning Tea and Coffee
11:00amAstute Documentation - Avoid Being The Invisible Nurse
What do the data entry times or notes on your medication charts or patient notes reveal about you? Concise documentation offers a clear picture of the progress – or lack of progress – of a patient condition. This session looks at the purposes of documentation and its characteristics, Standards of 'professional' language and statements. It includes:
- What contribution does competent documentation make to nursing care?
- How can timely documentation enhance a patient's care and protect a nurse' reputation or standing?
- When do nurses need to document the actions of other staff, such as when supervising Assistants in Nursing (AIN) or interactions with medical officers?
- How do you document objective 'radar' observations and subjective behavioral changes you have noticed?
11:45amSelf-Protection - Reporting 'High Risk' Situations and Incidents
Well considered professional documentation improves patient care, lowers risk and promotes quality. It is also a means of protecting your registration, reputation and income. This session will explore the notion of documentation as a form of personal protection. Includes:
- Tips on anticipating tricky situations which can become 'high risk' … for you
- Completing 'Riskman' incident reports and other timely ways of informing appropriate people
- Nurses' responsibility and authority - getting and giving instructions
- What does ISBAR mean to nurses?
12:00pm - Lunch Break and Networking
1:00pmFrom the Bedside Handover to the Patient
Communication, in many forms, is seen as an essential skill in nursing, particularly patient centred care. Yet, communication in its diverse forms can be a source of risk. This session considers some common scenarios related to communication. It will assist you to examine where in your practice you can enhance your accountability of your practice through sound communication. Includes:
- Speaking at the bedside handover
- The etiquette of bedside handover and talking about a patient/family
- Professional exchange of essential information for optimal patient outcomes
- Tips on writing sensitive matters in patient notes
- When you do (and don't) want to obey what the computer or the form instructs you to do
2:30pm - Afternoon Tea and Coffee
3:00pmSafe Use of Social Media - A Guide for Nurses
Some hand-held devices and small IT devices have helped improve patients' wellbeing in the home and hospital. However, one outcome is that nurses may unwittingly become 'movie stars' without their consent. This session looks at some of the pitfalls of social media for health professionals, including texting and taking photos with mobile phones whilst at work.
- Why has the NMBA warned nurses about using social media?
- What do nurses need to be wary of when posting on 'Facebook' and other social media sites?
4:15pm - Close of Day One of ProgramDay Two
9:00am - Commencement of Day Two
9:00amProtecting Your Nursing Qualifications and Your Income - What Does CPD Mean to You?
There have recently been some major changes in the regulation of nurses, which have profound implications for every registered nurse. The onus of responsibility for proving competence to practice lies firmly with each individual health professional, which means we nurses must have complete documentation in place to demonstrate the rationale behind your selection and undertaking of CPD activities.
Today’s program will explain the rationale behind the CPD policy, why we all need to take it seriously and how each of us can plan to achieve our career goals. This session will:
- Revise the differences between qualifications and registration both for nurses who are hospital trained and those with a nursing degree from a university
- Make a link between protecting your income and undertaking legitimate CPD
9:45amProtecting Your Registration With CPD
This session will use a case scenario to highlight the importance of CPD which is underpinned by evidence as a means of protecting your registration and therefore your livelihood. Come away seeing the value in ‘never giving up your clinical nursing skills and CPD’.
How does a nurse who has been employed for a long time in non-nurse activities (e.g. medical secretary, drug company representative, beauty therapist) end up no longer sufficiently competent to remain registered as an enrolled or registered nurse?
10:30am - Morning Tea and Coffee
11:00amCPD - Troubleshooting and Clarification
This interactive session will help clarify some of your questions on CPD. Includes:
- Why did CPD become mandatory?
- What comprises legitimate CPD for nurses and midwives?
- What sort of learning activities fulfil the CPD requirements?
- Calculating your individual learning requirements
11:45amHow and Where Can You Document Your CPD?
This session will help you understand how to document audit-proof CPD. Includes:
- More than just certificates - what sort of 'proof' is required to be included in your CPD portfolio?
- Advantages of documenting and storing your CPD online and how this might assist you in the future
- Recouping CPD costs and tax rebate claims
12:30pm - Lunch Break and Networking
1:30pmStrategic Planning and CPD - Aligning Your Learning to Match Your Career Goals
In this session you will document how you identified the gap in your knowledge, wrote the need for your personal education, planned and selected your activity and evaluated the outcomes. Reflection will be encouraged on the following:
- What topics do you need to explore for your current job?
- Should you include things such as, ward orientation, policy development projects?
- How can you be sure the education you receive is reputable?
- What topics might you include toward your future career goal?
- What learning/teaching methods suit you best?
- Match your time constraints, interests and learning styles for CPD
2:30pm - Afternoon Tea and Coffee
3:00pmPlanning Your Next Career Move
Knowing your next career goal should influence the CPD activities and topics you undertake now. This will help ensure your learning will impact on your documentation skills/and 'voice' as a confident professional nurse. This is time to imagine your next career move which may include ideas about:
- Gaining post-graduate qualifications related to nursing or something different
- Job-sharing or changing from full-time to part-time work
- Transitioning into semi-retirement
- Up-skilling for nurse specialist or consultancy
- Moving between private and public employment sectors
4:15pm - Close of Seminar and Evaluations
Dr Vivien Lane is a nurse clinician specialising in oncology and palliative care, with over three decades’ experience in education, research and policy-making. Vivien's doctorate (2001) developed a 'nursical' perspective on women's experiences of pap smears and her research findings predicted by over a decade the paradigm shift towards vaccinating both sexes against human papilloma virus (HPV). Vivien has held academic appointments with the University of Technology (UTS) and the University of Sydney, and she was a member of the inaugural Board of the Cancer Institute NSW.