Clinical Documentation

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Clinical Documentation - Course Summary

  1. Course Overview
  2. Course Topics
  3. Course Objectives

This one-day course has been developed for nurses working in hospitals, clinics and communities, to assist with developing a better understanding about the gaps in and importance of, accurate clinical documentation. The main objective of this course is to increase your knowledge and change attitudes towards clinical documentation, to reduce the likelihood of errors.

It is estimated that one in three healthcare workers will be directly involved in legal proceedings during their career. The public has become increasingly aware of their rights and are more prone to litigation than in the past. Because of increased acuity of inpatients, documentation is sometimes seen as taking time away from patient care. However, nursing documentation is vital for good communication.

Poor communication (including clinical documentation) has been proven as a root cause for as many a 70% of adverse events in hospitals.

Course topics include:

  • Clinical documentation: what healthcare workers should know
  • Legal principles of clinical documentation (including narcotic documentation)
  • Communication tools to improve patient safety (including a ‘Do Not Use’ abbreviations list, MEWS, SBAR and surgical safety checklist)
  • Risk assessment documentation (including MEWS, skin assessment and falls assessment documentation)
  • Writing patient care plans based on SMART goals (with practical scenarios)
  • Adverse event reporting
  • The importance and process for conducting clinical audits

On completion of the course, you should be able to:

  • Discuss how adhering to the legal principles of clinical documentation can prevent adverse events and legal action against nurses and their employers
  • Describe the importance of communication in emergency teams and the eight elements of good team dynamics
  • Write a scenario-based nursing care plan with a relevant nursing diagnosis, based on objective and subjective data, SMART goals and nursing interventions
  • Describe the benefits of and the barriers to the successful implementation of clinical audit programs in healthcare facilities
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Call us on +971 2 643 7720 or email This email address is being protected from spambots. You need JavaScript enabled to view it. for course dates and registration options

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