PPE3 Reflection

This is a reflection of my learning experience in the

Clinical Practice Unit (CPU) labs as I was not allocated a
clinical placement at this time. The reflection is written in
guidance of the Gibbs Reflective Cycle (Cheltenham,
2003) in which I am able to critically reflect on my legal
documentation writing experience within in the clinical
practice unit. I was required to write nursing notes in
Workshop A of a class in week three after forming into
groups and caring for a patient at their bedside in order to
complete the tasks required for the case scenario given.

All nurses will follow the Code of Ethics for Nurses in

Australia. Number seven, is Nurses value ethical
management of information. ((NMBA), 2008) which
directly relates to the explanation of Conduct Statement 2
in the Professional Code of Conduct for Nurses in
Australia; Nurses practice in accordance with wider
standards relating to safety and quality in health care and
accountability for a safe health system, such as those
relating to health documentation and information
management ((NMBA), 2008).

As a practicing Endorsed Enrolled Nurse in the hospital

setting, I felt nervous knowing my writing skills will be
assessed out of the workplace/hospital environment
because it is a daily task I complete on each shift at work
and although I understood the importance of writing
documents legibly and legally, I did not believe it had to
be done with so much detail and precision until after
receiving feedback as a nursing student from my tutor. I
was taught by my fellow workmates/nurses to incorporate
note writing for each patient into my routine of care
provided. In a ward setting, I have observed that many
nurses only have enough time to write one or two nursing
entries per shift therefore limiting them with only a
specific amount of time and only so much information
they can write per each entry. I myself have had to stay
back from breaks previously, just so I could sit down and
write notes and document my care provided for a patient.
It is a form of evidence. I now feel more confident with

writing more detailed patients notes because in reality, as

I have now learnt from CPU classes, I now know that
records should be written at the time of events, or as soon
as possible afterwards. (Hugh McKenna, 2008)

After completing the tasks given in class, I sat down and

wrote an entry on a progress note paper. I wrote it as a
Student nurse, but exactly how I would write it as a
practicing Enrolled nurse at work due to my curiosity of
exactly how developed my skills were and to determine
which areas required further development. This was a
positive aspect of the experience, as many details had
initially been left out because on the ward, the nurses
eventually know their patients well after a couple of days
and therefore do not re-document information in the
progress notes that has already been recorded in another
official chart or that has been included in the clinical
handover. (Dr Kwang Chien Yee Associate Professor,
2010) I had left out information such as the name of the
intern paged, why the ECG was attended, what actions I
took regarding only a 10ml urine output, where the stoma
was actually located, what the appearance of the stools
looked like, and that bowel sounds were heard via
auscultation. After picking up on these vital facts which I
should have written, as a Student nurse I felt that I had
picked up on bad habits from my peers at work which
was a negative aspect of the experience.

I also learnt that Ward progress notes and Emergency or

Preoperative notes differ slightly in nature and they are
not all the same although they are all meant to be written
subsequently. My tutor taught me how to use the
acronyms PVITAL (Patients story + meds & allergies,
Vitals, Input/ Output, Treatment, Admit or Assessment,
Legal waterlow, falls risk, pts valuables, etc.) and
ABCDEFG to ensure all information was included, not
to use subjective words, to keep the notes factual, with a
logical flow and how to sign off as a WSU Student Nurse
properly.

Progress notes and any other form of nursing

documentation is crucial for good communication
between other nurses and allied health workers. Legible

documentation provides an accurate reflection of nursing

assessments, changes in conditions and care provided.
(Sophie Linton, 2014). Documentation provides
evidence of care and is a legal requirement through
nursing practice. My experience of learning how progress
notes should be written in CPU can now be applied to my
daily note writing at work. As I work in a ward, I can
write End of shift progress notes which is documentation
written as a summary at the end of the shift. Keeping it
sub sequential but, including every small detail as
mentioned above to ensure clarity of my care given and to
be more precise for the multidisciplinary team to deliver
greater care at my workplace.

References
(NMBA), N. a. (2008). Australian Health Practitioner Regulation Agency. Retrieved
from AHPRA: http://www.nursingmidwiferyboard.gov.au/Codes-GuidelinesStatements/Professional-standards.aspx
Cheltenham, N. T. (2003). Beginning Reflective Practice. Jasper M.
Dr Kwang Chien Yee Associate Professor, C. J. (2010). Australian Commission on
Safety and Quality in Health Care (2010). The OSSIE Guide to Clinical
Handover Improvement. Sydney, ACSQHC. Retrieved from OSSIE Guide to
Clinical Handover Improvement: http://www.safetyandquality.gov.au/wpcontent/uploads/2012/01/ossie.pdf
Hugh McKenna, O. S. (2008). Vital Notes for Nurses: Nursing Models, Theories
and Practice. In O. S. Hugh McKenna, Vital Notes for Nurses (pp. 166-167).
the University of Michigan: Wiley.
Sophie Linton, C. N. (2014, November). Clinical Guidelines for Nursing
Documentation . Retrieved from The Royal Children's Hospital Melbourne:
http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_Do
cumentation/

(Cheltenham, 2003): Jasper M 2003 Beginning

Reflective Practice Foundations in Nursing and Health
Care Nelson Thornes. Cheltenham