Professional codes and guidelines in combination with organisational and institutional policies and procedures identify and benchmark the standards of good documentation practices within a health care context. The Nursing and Midwifery Board of Australia has adopted, as part of the regulatory framework for nursing and midwifery practice, the principles essential for good documentation. Although these principles have remained unchanged for decades, issues based on poor documentation practices continue to be raised in courts and tribunals. This column seeks to highlight the importance of recognising documentation as a valuable clinical activity and therefore deserving of closer attention and adherence.
Australia Documentation