Accurate Documentation for Care Workers

Accurate Documentation for Care Workers

AMC and eLearning Products
Updated Oct 14, 2019

Course Description

  • Aged Care Quality Standards ACQS 2, 7
  • National Standards for Disability Services NSDS 6 (all)

As a care worker you will be required to document your client’s progress and complete a number of charts such as medication charts, food charts, pain charts and sleep charts. It is your responsibility to document these concisely and using language that is factual, using industry standard abbreviations and writing styles. Your notes are a legal document that may be used in a court of law, so it is imperative that you follow the guidelines in this module. This module is part of an award winning suite of products designed to keep your workplace safe.

Course Summary

In this course the following areas will be covered:

  • The importance of accurate documentation
  • The extent of problems when documentation is inaccurate
  • How to write objectively
  • How to write concise and appropriate notes
  • Documenting refusal of care

Business Outcomes

In the event of legal proceedings, your staff’s documentation may be critical in establishing that your duty of care was carried out towards a client. Accurate and concise documentation following industry standards will also ensure that all documents are recorded correctly and reflect client choice, participation and feedback.

Learning Outcomes

Participants will be able to…

  • Recognise the importance of documentation
  • Recognise the issues that can arise through inaccurate or subjective documentation
  • Identify the difference between objective and subjective documentation
  • Identify concise documentation using industry standard abbreviations
  • Learn to document refusal of care

This course was part of a suite that won a 2019 Platinum LearnX Live! Award.