400732 Lecture Notes - Lecture 11: Health Professional
22 Jun 2018
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Week 12 – Documentation
PRE-TUT week 12
As a health professional you will be expected to document every interaction you have with your
client and allied health professionals. In preparation for your tutorial this week, list the top five
reasons you believe documentation is required based on your lecture and readings. After that,
write a short paragraph on how can health professionals demonstrate respect when creating
health documentation?
1.Demonstrates a professionals decision making process - which is important as it shows the
direct links between client goals and interventions
1.To provide proof of necessity - demonstrates that the services or interventions provided are
necessary, proves that the client is an advocate for services
2.To give feedback - gives feedback of client results
3.Funding and resource management - can identify the type of care that the client requires,
the services provided to the client and the effectiveness of the care
4.Quality improvement and research - can be used to evaluate professional practice, provide
information in relation to clinical intervention & client outcomes, as well as it can be utilised to
obtain accurate research data
Health professionals can demonstrate respect through their documentation by maintaining a level of
integrity in the language that they use. By writing in a professional language a health professional
can reduce the risk of misinterpretation, uphold the reputation of themselves as a professional and
most importantly maintain respect from clients and peers.
LEC
Documentation
ď‚·Is recorded in a professional capacity in relation to the provision of patient care
ď‚·Demonstrates the clinicians accountability and records their professional practice
ď‚·Records professional practice
ď‚·Its important to record client data: regarding events of interaction, assessment results, to
demonstrate improvement or worsening condition
Why document?
Demonstrate professional decision making process
ď‚·Reflects logical decisions and sound judgement - show direct links between client goals and
interventions
ď‚·Assists in continuity of care whereby clients might be seen by multiple health professionals
To provide proof of necessity
ď‚·Demonstrate that the services provided are necessary
ď‚·Client advocate for services
ď‚·Professional advocate for services
ď‚·Accountability - legal requirements
In the event of legal action
ď‚·Clients notes are legal documentations - can be used as evidence in a trial
ď‚·Can support yours or the clients case if something goes wrong
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
As a health professional you will be expected to document every interaction you have with your client and allied health professionals. In preparation for your tutorial this week, list the top five reasons you believe documentation is required based on your lecture and readings. 1. demonstrates a professionals decision making process - which is important as it shows the direct links between client goals and interventions. 1. to provide proof of necessity - demonstrates that the services or interventions provided are necessary, proves that the client is an advocate for services. 2. to give feedback - gives feedback of client results. 3. funding and resource management - can identify the type of care that the client requires, the services provided to the client and the effectiveness of the care. 4. quality improvement and research - can be used to evaluate professional practice, provide information in relation to clinical intervention & client outcomes, as well as it can be utilised to obtain accurate research data.
