Documentation in Nursing and Midwifery

In this webinar we will explore the work of Tanya Langtree and Elspeth Wood from James Cook University as we investigate their publication Documentation in Nursing and Midwifery: Australian edition. Nurses and midwives are legally obliged to complete documentation. There is a duty of care to avoid acts or omissions, which could be reasonably foreseen to injure or harm other people. In this session we will explore the legal obligations and documentation concepts of Nurses and Midwives.
CPD HOURS: 1
 Registration Year 2025/2026

Course Content

Documentation constitutes the enduring archive of all care interactions. It encompasses all forms filled out during an episode of care by any member of the healthcare team involved in an individual's care. Together, these documents provide the official and legal account of the care delivered to a person during their pursuit of healthcare services.

While data is collected and recorded differently in paper-based records and EHRs, the principles for producing quality documentation are largely the same.

Nurses and midwives are legally obliged to complete documentation. There is a duty of care to avoid acts or omissions, which could be reasonably foreseen to injure or harm other people.

This duty of care means that you must anticipate risks for the people you are caring for and undertake preventive strategies to mitigate this risk.

A significant component of this process includes timely and accurate documentation to promote communication for safety.

In this webinar we will explore the work of Tanya Langtree and Elspeth Wood from James Cook University as we investigate their publication Documentation in Nursing and Midwifery: Australian edition.

Learning Outcomes

In this session, you will:
  • Describe the purpose for documentation
  • Discuss the ethicolegal and best practice standards for documentation
  • Outline the recommended guidelines for effective documentation
  • Identify and discuss the characteristics of key documentation frameworks

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Sue Walker

RN, BN, BN (ADMIN), MPHC, MACN

Sue is the Director and Co-Founder of Nurses for Nurses (NFNN), delivering national and international conferences, study tours and professional development programs for nurses and midwives. She is also a key contributor to Nursing CPD, an online education platform supporting nurses to meet NMBA Continuing Professional Development requirements through accessible, evidence-based learning that is firmly grounded in real-world practice.