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It’s All in the Delivery: Improving Clinical Documentation in the Community Healthcare Setting

South Eastern Sydney Local Health District
Project Added:
26 September 2016
Last updated:
21 April 2021

It’s All in the Delivery: Improving Clinical Documentation in the Community Healthcare Setting


The project will identify barriers to compliance and introduce solutions that aim to improve nursing assessments for new admissions at St George Hospital.


To improve clinical documentation of new admissions by Community Health nurses, to 90% within six months.


  • Improves nursing assessments on admission through standardised nursing care plans.
  • Allows nursing staff to identify and address healthcare needs in a timely manner.
  • Reduces the risk of medical complications due to late diagnosis and intervention.
  • Reduces readmissions and morbidity through early detection and intervention of health issues.
  • Promotes clear communication and documentation, which improves patient care.
  • Addresses National Safety and Quality Health Service Standard 1 (Governance for Safety and Quality in Health Service Organisations)1 and Standard 6 (Clinical Handover)2.


Clinical admission notes are a record of the care provided to patients and provide a clear picture of their situation and background. They are a legal transcription and vital source of information to drawn on, in the event of adverse clinical outcomes. Nurses are advised to review previous clinical notes when patients visit the hospital on subsequent occasions, to understand their diagnosis, care plan and requirements for their condition.

Anecdotal evidence from nursing staff at St George Hospital showed that many clinical admission notes did not contain referrer details, procedures performed or a care plan for the patient. In some cases, the clinical presentation of the patient was not documented, which meant there was no baseline that could be used to compare new observations. This information was often available via other sources, however it was not always readily available and proved time consuming to collect. The issue of poor documentation seemed to be correlated with an increase in nursing workloads and intensity of patient needs.

An audit of 22 clinical admission notes from Community Health nurses at St George Hospital was conducted in June 2016, with two notes from each case manager selected at random. The audit was developed using a combination of NSW Health policy directive PD2012_06913 and SESLHD procedure ‘Documentation in the Health Care Record’4. It measured the following criteria:

  • inclusion of an objective perspective
  • inclusion of a care plan
  • completion of relevant associated documentation, such as wound care charts
  • identification of risks and evidence of interventions associated with these risks
  • statement of referral source and purpose of referral
  • use of approved and non-approved abbreviations
  • use of medical terminology
  • use of inappropriate or unprofessional language
  • relevance of information
  • appropriate use of the patient’s personal information
  • documentation of changes to the patient’s condition.

The audit revealed a 73% compliance rate, as well as a lack of vital patient information and nursing care planning. This may contribute to adverse outcomes for patients through a lack of communication, poor care planning and untimely interventions in the event of clinical deterioration.

It was determined that identifying the root causes of this issue and implementing strategies to improve clinical admission documentation would reduce the risk of readmissions and morbidity, through earlier detection and intervention of healthcare issues.


  • A project team of key stakeholders was created, with an initial meeting arranged to develop a flowchart of current processes and identify primary and secondary drivers of the issue.
  • Possible solutions will be formulated and implemented as per guidelines provided by the Clinical Excellence Commission and Clinical Leadership Program5.
  • Plan Do Study Act testing cycles of solutions commenced in October 2016.

Project status

Sustained – The project has been implemented and is sustained in standard business

Key dates

July 2016 – December 2016

Implementation site

Extended Community Care Program, St George Hospital, South Eastern Sydney Local Health District (SESLHD)


Clinical Excellence Commission. Clinical Leadership Program


An audit conducted in January 2017 showed that compliance with clinical documentation of new admissions had increased to 92 per cent. This is a significant improvement on the baseline of 73 per cent and above the target of 90 per cent.


  1. Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide Standard 1: Governance for Safety and Quality in Health Service Organisations (October 2012). Sydney. ACSQHC, 2012.
  2. Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide Standard 6: Clinical Handover (October 2012). Sydney. ACSQHC, 2012.
  3. Ministry of Health. Health Care Records - Documentation and Management. Policy Directive PD2012_069. North Sydney: NSW Health; 2012.
  4. South Eastern Sydney Local Health District. Documentation in the Health Care Record. Procedure SESLHDPR/336. Randwick: SESLHD; 2014.
  5. Clinical Excellence Commission. Clinical Leadership Program


Sally Plumer
Clinical Nurse Coordinator
Extended Community Care
St George Hospital
South Eastern Sydney Local Health District
Phone: 02 9113 3999

Keith Jones
Clinical Facilitator CEC Clinical Leadership Program
Nursing & Midwifery Practice & Workforce Unit
South Eastern Sydney Local Health District
Phone: 02 9947 9867 / 0428 259 325

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