Professional Perspectives
Profession Perspectives
Standards of documentation
I am concerned that I am being encouraged by my workplace to document in a way that would not be considered ‘best practice’ – is this illegal?
All nurses and midwives must meet the Nursing and Midwifery Board of Australia (NMBA) professional standards to practice in Australia.
These professional standards define the practice and behaviour of nurses and midwives and include codes of conduct, standards for practice, and codes of ethics.
They can be found on the NMBA website: https://www. nursingmidwiferyboard.gov.au/ Codes-Guidelines-Statements/ Professional-standards.aspx.
These professional standards outline the need to provide privacy, dignity, and confidentiality when providing care. They also outline the need to document accurately and clearly. At a workplace level, facilities may have specific policies that outline specific requirements for documentation.
As a nurse or a midwife, you must adhere to the NMBA professional standards and to any workplace policies. You can always contact the NSWNMA for advice about professional practice issues. We also have a documentation webinar available to view anytime on Member Central.
Mandatory notification of staff health issues
I am a NUM, and a staff member has revealed to me that they have a longstanding diagnosis of bipolar affective disorder. There are no issues with their performance and no concerns have been raised. Do I have to make a mandatory report or tell the staff member to report themselves to the NMBA due to their diagnosis?
As per AHPRA, a health issue rarely needs a mandatory notification. Under the national law, health practitioners are expected to make a mandatory notification if there are concerns that a health practitioner has an impairment that does or may adversely affect their capacity to practice. The four concerns under the national law are:
- impairment
- intoxication while practicing
- significant departure from accepted professional standards
- sexual misconduct.
A mandatory notification is not automatically required for a practitioner living with a mental health condition or diagnosis or any other health condition. Any decision to make a mandatory notification should be based on a risk assessment to determine whether they are placing the public at risk of substantial harm. For a practitioner living with a mental health condition that is not presenting any impact to their provision of safe patient care, there is no requirement to make a mandatory notification. There is an onus on the employer to implement strategies to mitigate risk, this includes working with practitioners to ensure that strategies are in place to support and promote mental and physical wellbeing and could include consideration of rostering, workplace support and leading a positive and respectful workplace culture.
Comprehensive information regarding mandatory notifications can be found here