assessment skills to clarify and identify the person’s health problem, birthing/parenting support and related needs. The needs might relate to care while an inpatient or it might relate to their needs when they go home. It is essential that an interprofessional collaborative approach is used to plan care that is person-centred. Communicating effectively together (and with the person receiving care) enables healthcare team members to support and complement one another’s services and avoid duplications and omissions in planning and coordinating care. Nurses and midwives in their various roles can advocate for that person’s holistic needs to be met through effectively documenting needs, making referrals through face-to-face meetings and consultation with other professionals. This chapter discusses the different ways nurses and midwives properly document care, report care and how they formally confer with others to ensure people’s continuity of care needs are met. In Australia and New Zealand, the current healthcare system requires that all nurses and midwives are competent in documenting their client’s care to ensure continuity of care, that legal records are kept about the care given so that the documentation can also provide a trail and evidence for evaluating and auditing the effectiveness of the care given (Blair & Smith, 2012). Documentation of care is therefore an important source of reference and communication between all health professionals including nurses and midwives, with implications for continuity of care and interprofessional collaborative practice. The health standards set by government accrediting bodies in Australia and New Zealand has specific guidelines for documenting clinical data and care. Nurses and midwives need to document concisely, and have a system of non-duplication and evidence-based care to ensure quality and safety. The following section explores documentation and some of the different ways and systems of documenting care that are used in our healthcare services. DOCUMENTING CARE Documentation is any written or electronically generated legal record of all pertinent interactions with the client that describes the care and services provided to that person. Documentation is a written record of the healthcare professional interacting with the person on all levels of care including assessing, identifying health problems, and planning, implementing and evaluating care. Increasingly sophisticated management information systems (MIS) are becoming available to manage patient- specific data and information, as well as provide access through clinical databases for evidence-based practice. The data obtained from a MIS are used to facilitate person care, serve as legal records, help in clinical research and support decisio.

1. assessment skills to clarify and identify the
person’s health problem, birthing/parenting
support and related needs. The needs might
relate to care while an inpatient or it
might relate to their needs when they go
home.
It is essential that an interprofessional collaborative
approach is used to plan care
that is person-centred. Communicating effectively
together (and with the person
receiving care) enables healthcare team members to
support and complement one
another’s services and avoid duplications and
omissions in planning and coordinating
care. Nurses and midwives in their various roles
can advocate for that person’s
holistic needs to be met through effectively
documenting needs, making referrals
through face-to-face meetings and consultation with
otherprofessionals. This chapter
discusses the different ways nurses and midwives
properly document care, report
care and how they formally confer with others to
ensure people’s continuity of care
needs are met.
In Australia and New Zealand, the current
healthcare system requires that all
nurses and midwives are competent in
documenting their client’s care to ensure
continuity of care, that legal records are kept

2. about the care given so that the
documentation can also provide a trail and evidence
for evaluating and auditing the
effectiveness of the care given (Blair & Smith,
2012). Documentation of care is
therefore an important source of reference and
communication between all health
professionals including nurses and midwives,with
implications for continuity of care
and interprofessional collaborative practice. The health
standards set by government
accrediting bodies in Australia and New
Zealand has specific guidelines for
documenting clinical data and care. Nurses and
midwives need to document
concisely, and have a system of non-duplication
and evidence-based care to ensure
quality and safety. The following section
explores documentation and some of the
different ways and systems of documenting care
that are used in our healthcare
services.
DOCUMENTING CARE
Documentation is any written or electronically
generated legal record of all pertinent
interactions with the client that describes the care
and services provided to that
person. Documentation is a written record of
the healthcareprofessional interacting
with the person on all levels of care including
assessing, identifying health problems,
and planning, implementing and evaluating care.
Increasingly sophisticated
management information systems (MIS) are
becoming available to manage patient-

3. specific data and information, as well as provide
access through clinical databases
for evidence-based practice. The data obtained from
a MIS are used to facilitate
person care, serve as legal records, help in
clinical research and support decision
analysis. The aim of thesesystems is to create an
environment that supports timely,
accurate, secure and confidential recording and use of
patient-specific information.
Hall, H. H. R. T. C. (2016). Fundamentals of Nursing and
Midwifery. : Wolters Kluwer Health. Retrieved from
http://www.ebrary.com
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5. MIS can include traditional patient records in
hard copy to patient records and data
systems that are electronic. In the recent years,
there has been a strong shift to
healthcareservices using and trialling different
electronic MIS.
Nurses or midwives are required to document care in
a variety of systems, all of
which are reviewed regularly and revised so that
the end goal of the most efficient,
effective and cost-effective quality care can be
delivered to clients. The nurse or
midwife needs to ensure that due to these
processes of quality improvement, the
most up-to-date forms, documents and systems
are utilised so that there are no
errors in delivery of care. Organisations and
healthcareservices will have a process
of document and system control to ensure
records are accurate. Check with your
organisational policies and procedures to comply
with their standards. You are
expected to practise according to thesespecific policies
and professional standards.
Patient record
The patient record is the written record of a
person’s progress and care and a
compilation of health-related data. The manner in
which a patient’s record is
documented and filed reflects the specific policies of
the healthcarefacilities in which
nurses and midwives work.

6. Electronichealth records
The increasing integration of health records
and information systems is providing
benefits for clinicians and people by allowing for
the delivery of more efficient care;
and for the healthcare system through the
collection of better data for policy
development and resource allocation. Shared
electronic health records (EHR)
provide efficiencies throughout the healthcaresystem.
A patient’s record needs to be
created once only,saving hours of timeclinicians
currently spend re-entering basic
details such as names, addresses, birth
dates, medical history and things like
allergies and current medications. A personally
controlled electronic health record
(PCEHR) is an electronic system of storing a
patient’s records that can be accessed
within eHealth systems under the governmental
health services in Australia and New
Zealand. These are not yet compulsory and people
must register to have their own
record system established electronically. There
are strong security and safeguards in
place to keep information safe (Department of
Health, 2015; Manage My Health,
2015), just as thereare processes in place to
ensure the information can be shared
when required. There has also been development of
smart device applications (apps)
that facilitate the use of theseprograms. The increasing
use of computerised PCEHR
systems to store and analyse data has necessitated
the development of policies and
procedures to ensure the privacy and

7. confidentiality of information. Policies should
specify what types of information can be
retrieved, by whom and for what purpose.
Consent is necessary for the use and release of
any stored information that can be
linked to the person.
The development of electronic transfer of health
and health-related data between
Hall, H. H. R. T. C. (2016). Fundamentals of Nursing and
Midwifery. : Wolters Kluwer Health. Retrieved from
http://www.ebrary.com
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9. 30028780
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15Chapter two Key attributes of patient-safe CommuniCation
patient-Centred Care
Recognition that patient-centred care is arguably the most
important attribute of patient-safe
communication is changing the landscape of contemporary
healthcare and health professional
education. The traditional view of patients as passive recipients
of care has given way to one where
patients are seen as active participants and integral members of
the healthcare team. Patients (and
their families) are now seen to have a vested interest and
valuable perspective in ensuring safe care.
There are various definitions of the term ‘patient-centred care’,
with each underpinned by
principles such as empathy, dignity, autonomy, respect, choice,
transparency, and a desire to help
individuals lead the life they want. Patient-centred care is built
on the understanding that patients
bring their own experiences, skills and knowledge about their
condition and illness. It is a holistic
approach to the planning, delivery and evaluation of healthcare
that is grounded in mutually
beneficial partnerships between healthcare professionals,
patients and families. Patient-centred care
applies to people of all ages and can be practised in any

10. healthcare setting (Institute for Patient- and
Family-Centered Care 2008).
Health professionals who practise patient-centred care are
ethical, open-minded, self-aware and
have a profound sense of personal responsibility for actions
(moral agency). They place the ‘person’ at
the centre of healthcare and consider their needs and wishes as
paramount (Victorian Government
Department of Human Services 2006). Patient-centred
clinicians:
• appreciate that people have a unique life history that
influences their healthcare experience
• seek to understand the patient’s perspective
• inform and involve patients in their care
• promote active involvement of family and friends
• elicit patient preferences
• check and confirm information with patients
• share treatment decisions
• respect patients’ culture, values and personal beliefs
• provide physical and emotional comfort and support
• maintain patients’ dignity
• design care processes to suit patients’ needs, not the
provider’s needs
• ensure coordination and continuity of care
• are transparent and provide access to health information
• are sensitive to non-medical and spiritual dimensions of
care
• guide patients to appropriate sources of information on
health and healthcare
• educate patients on how to protect their health and prevent
occurrence or recurrence of a
disease
• provide support for self-care and self-management
• communicate information on risk and probability.

11. Source: Gerteis et al. 1993; Robb & Seddon 2006; Shaller 2007.
protocols and policies. You can lock the door and say, “Sorry,
Mrs Gruzenski, your 30 minutes are
up.” But, you can also unlock the door. You can ask, “Shall I
call you ‘Dr Gruzenski’?” “Would you like
to be alone?” “Is this a convenient time?” “Is there something
else I can do for you?”’
Source: Reproduced with permission: Jocelyn Anne Gruzenski
and Dr. Donald Berwick.
Copyright © Pearson Australia (a division of Pearson Australia
Group Pty Ltd) 2014—9781486004270—Levett-Jones/Critical
Conversations for Patient Safety 1e
Levett-Jones, T. (2013). Critical Conversations for Patient
Safety. : Pearson Australia. Retrieved from
http://www.ebrary.com
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13. 30028780
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4 critical conversations for patient safety
patient safety and CommuniCation
Patient safety is defined as actions undertaken by individuals
and organisations to protect healthcare
recipients from being harmed by their healthcare (National
Patient Safety Foundation 2008). It is
important to note that patient safety is not limited to physical
safety but also includes psychological,
emotional and cultural safety. Patient safety is an attribute of
trustworthy healthcare systems
that work to minimise the incidence and impact of, and
maximise recovery from, adverse events
(Emanuel et al. 2008). Patient safety is considered to be one of
the most important issues facing
healthcare today. Health professionals need highly developed
communication skills in order to
manage the complexity and competing tensions that define
contemporary healthcare organisations.
Communication is much more than the provision of information,
instructions or advice. It is a
two-way interaction where information, meanings and feelings
are shared both verbally and non-
verbally and when the message being conveyed is understood as

14. intended (Dunne 2005). Many
health professionals think that effective communication means
giving patients clear, unambiguous
information in a timely manner. This is true, but it is only part
of the story. Communication involves
listening as well as talking. When we listen to patients, we are
less likely to jump to erroneous
conclusions because we haven’t seen the whole picture (this is
referred to as premature closure).
Patients expect to be communicated with in ways that are
inclusive, accurate, timely and
appropriate. The Australian Charter of Healthcare Rights (Box
1.1) outlines patients’ rights in
regards to healthcare and emphasises that communication and
working in partnership with patients
underpin safe care. Indeed, communication is considered by
many people to be one of the most
important aspects of quality healthcare. In 2009 Australian
patients and their families were surveyed
in an attempt to clarify what their priorities were when
undergoing healthcare (New South Wales
Health 2009). The list in Box 1.2 demonstrates the importance
of communication to the survey
participants’ healthcare experience and illustrates the particular
elements of communication that
they believed were key. It is noteworthy that the only other
clinical concern mentioned was in
relation to pain management.
Effective communication impacts on patient outcomes in many
ways. Studies have
demonstrated a relationship between effective communication
and compliance with medication and
rehabilitation programs, reduction in stress and anxiety (Harms
2007), improved pain management,

15. self-management, mood, self-esteem, functional and
psychological status (Goleman 2006),
symptom resolution, reduced length of hospitalisation, improved
coordination of care, reduced
costs (Mickan & Rodger 2005), reduction in surgical mortality
and post-operative complications
(Vats et al. 2010), enhanced patient satisfaction and wellbeing
(Mickan & Rodger 2005), improved
Box 1.1 the australian Charter of Healthcare rights
Safety – a right to safe and high-quality care
Respect – a right to be shown respect, dignity and consideration
Communication – a right to be informed about services,
treatment, options and costs in a clear and open way
Participation – a right to be included in decisions and choices
about care
Privacy – a right to privacy and confidentiality of provided
information
Comment – a right to comment on care and having concerns
addressed
Source: The Australian Charter of Healthcare Rights, Health
Quality and Complaints Commission, Australian Commission on
Safety
and Quality in Health Care, Jan 2012.
Copyright © Pearson Australia (a division of Pearson Australia
Group Pty Ltd) 2014—9781486004270—Levett-Jones/Critical
Conversations for Patient Safety 1e

16. Levett-Jones, T. (2013). Critical Conversations for Patient
Safety. : Pearson Australia. Retrieved from
http://www.ebrary.com
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5Chapter one the relationship between CommuniCation and
patient safety
patient safety, and error reduction (Abbott 1998). In contrast,
poor communication can lead to
hostility, anger, confusion, misunderstanding, lack of trust, poor
compliance and greatly increased
risk of error and patient harm.
Patient-safe communication is a goal-orientated activity focused
on preventing adverse events
and helping patients attain optimal health outcomes. It is a

18. means by which health professionals
gather and share information, clarify and verify accurate
interpretations of information, and
establish a process for working collaboratively with both
patients and other health professionals
to achieve common goals of safe and high-quality patient care
(Schuster & Nykolyn 2010). Every
aspect of patient care depends upon how well healthcare
professionals communicate with each
other and the patients they care for. Clinical decisions based on
incomplete or misinterpreted
information are likely to be inappropriate and may cause patient
harm and distress. For health
professionals, unsafe communication is considered to be a
breach of professional standards and a
leading cause of litigation (Trede, Ellis & Jones 2012).
Examples of this may include:
• inadequate or inaccurate advice on self-management
• failure to communicate in ways that the patient and their
family can understand
• failure to disclose the risk of interventions and potential
complications
• failure to obtain valid consent to an
intervention/procedure
• failure to maintain client confidentiality
• failure to give the patient an opportunity to ask questions
• failure to respond appropriately to those questions
• failure to respect the opinion of a patient (even though the
patient’s opinion may be medically
inaccurate, their observations usually are accurate and can be
very valuable)
• failure to realise that, from the patient’s point of view,
there is no such thing as a ‘silly question’
• failure to realise that the way we talk with patients
(courteous, respectful, clear and jargon-

19. free) can be just as important as the content of what we actually
say to them
• failure to communicate with other relevant health
professionals to provide a reasonable
standard of care
Box 1.2 Patient survey: top priorities for healthcare
• Healthcare professionals discussing anxieties and fears
with the patient
• Patients having confidence and trust in healthcare
professionals
• The ease of finding someone to talk to about concerns
• Doctors and nurses answering patients’ questions
understandably
• Patients receiving enough information about their
condition/treatment
• Test results being explained understandably
• Patients having enough say about and being involved in
care/treatment decisions
• Being given information about patient’s rights and
responsibilities
• Staff doing everything possible to control pain
Source: New South Wales Health Nursing and Midwifery
Office, Essentials of Care Project. © New South Wales Ministry

20. of Health for
and on behalf of the Crown in right of the State of New South
Wales.
Patient-safe
communication is
a means by which
health professionals
gather and share
information, clarify
and verify accurate
interpretations
of information,
and establish a
process for working
collaboratively
with both patients
and other health
professionals to
achieve common
goals of safe and
high-quality patient
care (Schuster &
Nykolyn 2010).
Copyright © Pearson Australia (a division of Pearson Australia
Group Pty Ltd) 2014—9781486004270—Levett-Jones/Critical
Conversations for Patient Safety 1e
Levett-Jones, T. (2013). Critical Conversations for Patient
Safety. : Pearson Australia. Retrieved from
http://www.ebrary.com
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