Documentation

NSW Health records

Referrals, clinical information and care plans are documented in a child or young person’s eMR, in accordance with the NSW Health Care Records – Documentation and Management (PD2012-069) and line with local health district processes. This includes recording:

• date of client’s referral to the WHIN Coordinator program, including uploading of any completed Referral forms where possible
• any record of client’s consent, including uploading completed Consent form where possible
• each contact attempt with client and missed appointments
• dates of initial and follow up appointments with clients
• mode of service delivery for each service event with client and/or their family members
• people present with the client at the appointment with the wellbeing nurse
• home visiting risk assessments
• outcome of assessment of student’s sufficient understanding and intelligence to fully understand what is proposed in terms of the wellbeing assessment and sharing of the health information with other services if required
• completed client’s health and/or wellbeing assessment forms
• client’s assessed health needs
• supports provided to client
• agreed care plan or interventions for addressing client’s health and wellbeing needs
• referrals made to services and supports and referral outcomes
• progress of client and any changes to presentation, including changes to risk and care plan
• date and record of clinical review meetings and discussions with clinicians involved client’s care
• date and record of discussions with school staff and learning and support and wellbeing team meetings regarding required supports and care of a student
• date and record of discussions with other agencies and decisions regarding supports for a client
• uploading completed NSW Health information exchange forms where possible
• date of client’s discharge from the WHIN Coordinator program.

All paper and electronic client health information must be kept secure and disposed of in accordance with the NSW Health Records – Documentation and Management (PD2012_069), the NSW Health Privacy Manual for Health Information and local health district policies and procedures. This includes:

• keeping all paper copies of client health information in lockable storage or secure access areas when not in use until they can be scanned and integrated within the client’s health record and correctly disposed of
• maintaining a secure electronic environment for all client health data held on computer systems
• disposing of paper or electronic client health information in a manner that preserves the privacy and confidentiality of health record information e.g. shredding or pulping or completely deleting from electronic device or server.

School records

The wellbeing nurse can record the following in the school’s centralised record system:

• student name
• dates of consultations with student
• date student is discharged from the WHIN Coordinator program
• when a student is taken off school ground to attend a health appointment.

In accordance with the Privacy Manual for Health Information,the information recorded in the school record system must not contain specific details of identified issues or referrals made to the wellbeing nurse or referrals made by the wellbeing nurse to other services.