Communication that respects privacy and an organisation’s requirements

An important part of clinical communication is the exchange of information about a person’s care that occurs between treating health professionals.

Structured, clear, and continuous communication facilitates continuity of care by all members of the care team and contributes to better patient outcomes by enabling information exchange.

Communication within an organisation acknowledges that an organisation will have procedures and information channels in place that support care across the organisation and the requirements of auditing and accreditation.


Privacy considerations

At all times the confidentiality and privacy of information and patients should be considered.

Respecting a person’s privacy will be part of a nurse’s interactions with patients, carers and families; with the care team; and across the organisation. This can include:

  • holding conversations in a private space e.g. close a door, move away from others
  • sharing information with peers which is relevant to the person’s care using discretion
  • respecting a person’s wish for privacy when documenting and sharing sensitive information
  • respecting a person’s cultural and religious practices and preferences
  • adhering to the organisation’s requirements when collecting disclosing health information.

Digital Health Australia provides guidance for health care professionals and organisations to use My Health Record safely and responsibly. 


Documentation

Information about a person’s care is communicated through clinical documentation or clinical records. These may be on paper, electronic or a combination.

These documents include

  • assessment and treatment notes
  • care plans
  • test results
  • whether the person has an ACP and where the documentation is
  • medication charts
  • checklists
  • transfer forms
  • clinical summaries
  • information sent to and received from specialists, community workers, general practitioners, hospitals, or aged care services

In practice

For complex patients, the list of minimum documentation requirements for safe care includes:

  • patient details
  • family and carer support details
  • document author and location
  • document recipients and location
  • encounter details
  • problems and diagnosis
  • clinical synopsis
  • relevant pathology and diagnostic imaging investigations
  • clinical interventions
  • medications

  • allergies and adverse drug reactions

  • alerts
  • arranged services
  • recommendations for management
  • information provided to patient, carer, and family
  • nominated primary health providers.
Tips

Use any acronyms and abbreviations consistently and use standardised terminology in written records.

Note your organisation’s policy on documentation.

Being succinct in presenting potential changes to a care plan can help especially in a busy work environment. Use dot points backed up with supporting evidence.


Visit ACSQHC - Documentation of information

Documentation of information (862kb pdf)

Tools

There are tools that can help with standardised documentation practice.

Aged care


    Primary health care
    • CareSearch host information on tools and forms for referral and care transitions
    • ELDAC Linkages toolkit hosts documents and templates to establish or improve linkages between aged care, primary care, and palliative care services.

    Hospitals
    • BOOST (Better Outcomes for Older adults through Safe Transitions)
    • C-CEBAR (mnemonic)
    • D-SAFE (Discharge Summary Adapted to the Frail Elderly Patient)
    • DEFAULT (mnemonic)
    • INTERACT-II Stop and Watch Tool (mnemonic)
    • 7Ps flowchart
    • End-of-Life Essentials Toolkits can help facilitate communication within your organisation - promoting end-of-life knowledge, facilitating discussion and engagement of peers in end-of-life care, and accreditation processes.

    This information was drawn from the following resources:

    1. Australian Commission on Safety and Quality in Health Care (ACSQHC). Communicating with patients and colleagues [Internet]. 2022 [cited 2022 Sep 23].
    2. Australian Commission on Safety and Quality in Health Care (ACSQHC). Documenting information [Internet]. 2022 [cited 2022 Sep 23].
    3. Australian Commission on Safety and Quality in Health Care (ACSQHC). Documentation of information [Internet]. 2022 [cited 2022 Sep 23].
    4. Manias E, Bucknall T, Hutchinson A, Botti M, Allen J. Improving documentation attransitions of care for complex patients. Sydney: Australian Commission on Safety and Quality in Health Care (ACSQHC); 2017.

    Page created 23 September 2022

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