Download e-book Adventures in Clinical Record Keeping: An Easy Guide to Progress Notes

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A registered nurse is accountable for any delegation of record keeping to members of the multi-professional team who are not registered practitioners, such as assistant practitioners AP , care assistants and nursing students Jevon When caring for a patient, it is important to ensure good record keeping to promote patient care and better communication.

Good record keeping is a product of good teamwork and an important tool in developing high-quality healthcare and reinforcing professionalism within nursing. She uses her experience as a RN to write well-researched content that helps to attract and motivate audiences. Lydia is also a freelance writer for hire with specialisation in health writing and has helped numerous companies with their content needs. Contact Lydia or visit her website at Lnwritingservices. A good resource to remind us of the importance of timely and accurate record keeping.

This site complies with the HONcode standard for trustworthy health information: Verify here. Log In Join Ausmed. Where health professionals learn. Log In or. Assume that no records are immune from disclosure. Never alter records. Ways to correct not alter records Follow state, federal, professional organizations and HIPAA guidelines for record keeping. Not keeping any records is below the standard of care, is unethical and, in many states, illegal.

If the treating therapist becomes disabled, dies or cannot continue to provide care for other reasons, clinical records can help the next treating therapist with information and the clients with continuity. Guidelines: Store hard copy records in a safe, locked place that is reasonably protected from theft, intrusion, fire, earthquake, water damage and unauthorized access. Protect your computer records by use of password, virus protection, firewall and access log.

Backup regularly, and store your backup disks off site in a secure location. Print hard copies of very important documents and use access log if necessary. Enter clinically relevant and meaningful information in the clinical records. Detail clinically meaningful contacts, including important phone calls and important or clinically significant collateral contacts.

Include in records the date and type of services provided, fees, charges, payments, balances and copies of third party billing. Make sure that the records include basic demographic information, mental status exam and diagnosis or presenting problem does not need to be DSM diagnosis, can be familial, developmental, etc. Peter runs the business from his home and contracts a local courier company who employs a driver called Sandy to deliver the pre-cooked meals to customers.

A PCBU must ensure, so far as is reasonably practicable, the health and safety of workers, and that other people are not put at risk by its work. A PCBU who is a self-employed person must also ensure, so far as is reasonably practicable, his or her own health and safety while at work. The primary duty of care is a broad overarching duty.

It includes, but is not limited to, so far as is reasonably practicable:. PCBUs must also maintain any worker accommodation that is owned or managed by the PCBU and provided because other accommodation is not reasonably available. The PCBU must, so far as is reasonably practicable, maintain the accommodation so the worker is not exposed to health and safety risks arising from the accommodation. PCBUs must, so far as is reasonably practicable, provide and maintain a work environment that is without health and safety risks.

PCBUs must, so far as is reasonably practicable, provide safe plant and structures, and maintain them in good condition. It can be fixed, movable, temporary or permanent, and includes any component or part of a structure. The following are examples of structures:. PCBUs must, so far as is reasonably practicable, provide and maintain safe systems of work eg work processes. Developing a safe system of work is a formal procedure carried out by a person with sufficient knowledge and experience.

It involves:. The development of safe systems of work can involve looking at the physical layout of the workplace and its access and egress, tools, plant, procedures and people eg instruction, information, training. PCBUs must, so far as is reasonably practicable, make sure that plant, structures, and substances are safely used, handled and stored. PCBUs must, so far as is reasonably practicable, provide adequate facilities that are clean, safe, accessible, in good working order and maintained to stay that way for the welfare of workers. PCBUs must, so far as is reasonably practicable, make sure its workers and others are provided training, information, instruction or supervision to protect them from risks to health and safety.

The type of training, instruction or supervision required will depend on the nature of the work carried out and the experience of the workers, and the risk that workers and others, such as clients and customers, are exposed to. Monitoring is not a control measure to manage risk and does not replace the need for control measures to reduce exposure.

Results from monitoring should be used to improve control measures where needed. Workplace monitoring can involve measuring a hazard eg a substance, fumes, noise or vibrations arising from the work.


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The purpose of the monitoring is to assess the effectiveness of controls being used to minimise the risk of workers developing a work-related condition or getting injured on an ongoing basis. Health monitoring involves specific and targeted testing of the health of workers to identify potential signs of potential harm to their health and any changes on an ongoing basis. As well as identifying the development of work-related conditions, the purpose of monitoring is to assess the effectiveness of control measures designed to minimise potential harm to worker health on an ongoing basis.

In some situations a PCBU provides its workers with accommodation that it owns, or manages or controls, where this is necessary because other accommodation is not reasonably available. If this is the case, a PCBU must, so far as is reasonably practicable, maintain the worker accommodation so that workers are not exposed to health and safety risks arising from the accommodation. There are some duties that apply to PCBUs in certain situations.

These are outlined in sections 3. They expand on the primary duty of care.

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These PCBUs still have the primary duty of care. However, certain duties relate to workplaces. A PCBU who manages or controls a workplace must ensure that, so far as is reasonably practicable, the workplace, the means of entering and exiting the workplace, and anything else arising from the workplace are without health and safety risks to any person. PCBUs who manage or control workplaces do not owe this duty to anyone who is at the workplace for an unlawful purpose. A builder is making repairs to a commercial property.

Lines workers are carrying out a one-off repair of a power pole. Once they complete the work and leave, it is no longer a workplace for the lines company PCBU as the workers are not usually at that location for work. There is a clarification of these duties for farming businesses or undertakings.

For these, the duty of a PCBU who manages or controls a workplace applies only in relation to the farm buildings and any structures and part of the farm immediately surrounding the buildings needed for the operation of the farm. They do not apply to the family home, or to any other part of the farm unless work is being carried out there.

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However, the primary duty of care to ensure people are not put at risk by the conduct of work still applies. PCBUs who manage or control fixtures, fittings or plant at a workplace must, so far as is reasonably practicable, ensure that the fixtures, fittings or plant are without risks to the health and safety of any person.

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This could include consideration of the potential health effects from using the plant eg the long-term use of a vibrating tool causing damage to nerves or blood vessels in the arms or hands. PCBUs who manage or control fixtures, fittings or plant do not owe this duty to anyone who is at the workplace for an unlawful purpose. The duties apply in respect of plant, substances, or structures that are to be used, or that could reasonably be expected to be used, at a workplace.

Upstream PCBUs are in a strong position to eliminate or minimise risk. Upstream PCBUs can influence and sometimes eliminate health and safety risks through designing or manufacturing products that are safe for the end user. A poorly designed or manufactured saw eg that is not guarded as outlined in ASNZ creates the risk that it may injure the user. This risk is created by the saw designer and manufacturer the upstream PCBU. The risk will flow through to the downstream PCBU business that purchases the saw, and the workers who have to use the saw as part of a daily work activity.

PCBUs who are designers, manufacturers, importers or suppliers must, so far as is reasonably practicable, make sure that the plant, substances, and structures designed, manufactured, imported or supplied as relevant are without health and safety risks when they are used for their intended purpose in a workplace. Duties of PCBU designers, manufacturers, importers and suppliers of plant, substances and structures.


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  • Duties of PCBU installers, constructors and commissioners of plant and structures. Duty to, so far as is reasonably practicable, ensure plant, substances, or structures are without health and safety risks. Make sure, so far as is reasonably practicable, the way that the plant or structure is installed, constructed or commissioned is without health and safety risks to people who:. This includes information about:.

    What They Do

    On request, make reasonable efforts to give the current relevant specified information to a person who carries out or is to carry out work activities listed above with the plant, structure or substance. All PCBUs must involve their workers in workplace health and safety. A safe workplace is more easily achieved when everyone involved in the work communicates with each other to identify hazards and risks, talks about any health and safety concerns and works together to find solutions.

    Workers can also be represented by unions, community or church leaders, lawyers, respected members of ethnic communities, or people working on specific projects.

    Identification Products

    Risks to health and safety arise from people being exposed to hazards. A hazard is anything that can cause harm. Before deciding how to manage work risks PCBUs should think about risks more broadly across the work being conducted and the contributing factors. Risks must be eliminated so far as is reasonably practicable.

    Record Keeping Guidelines

    If a risk cannot be eliminated, it must be minimised so far as is reasonably practicable. PCBUs must take these steps to the extent within their ability to influence and control the matter to which the risks relate. The processes or equipment put in place to eliminate or minimise risk are called control measures.