Documentation in the person’s health care or medical record is an essential task when working in a health care environment.
An AHA will complete written communication as part of their work role.
Written communication can be paper-based, electronic or a mix of both. It can also take a number of forms or types including:
documentation in a client’s health care record
completion of written handover notes to the AHP
completion checklists, therapy records and discharge summaries
providing written information, such as education material, to clients.
Documentation in a client’s health care record is used as a written communication tool between all health care staff involved with the client, and is a legal requirement of practice.
A health care record is a complete, permanent and continuous record of a client’s care.
Documentation needs to be in accordance with organisational documentation procedure. Each organisation will have their own protocols, policies or procedures for documentation. This will include approved abbreviations, terminologies and documentation standards. Documentation must occur after each client contact or therapy intervention. If it isn’t documented, it didn’t happen!
