Topic outline
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An important part of students' clinical learning will be documentation of the clinical care they provide. As they progress in your studies, you will be able to notice improvements in their documentation, being able to link to theoretical learning and draw on previous experiences. Practising documentation helps them to develop important clinical reasoning skills. The more detail they include in clinical documents, the more they are able to demonstrate capacity to understand the clinical care that has been provided and how this affects the woman and her baby.
The purpose of the clinical experience documents in PebblePad is twofold. Firstly, they provide evidence that the student has met the minimum requirements for registration as defined by ANMAC and UniSA. They are also used as a tool to promote learning. We want our students to be competent in the provision of clinical care and this means that they will be able to demonstrate critical thinking and clinical reasoning. These skills will develop as they progress through the program as they add to their knowledge and skill base, however the clinical experience documents will be instrumental in helping them to 'think like a midwife'.
Students need to look at the 'big picture'. When completing your clinical experience documents, they must consider all aspects of care.
- What is the rationale for undertaking the assessment or providing the care?
- Are there any risk factors present? What are they?
- What clinical history is important?
- Are there any symptoms that should be documented?
- What assessments were undertaken and what were the findings?
- What investigations or tests were undertaken and what were the findings?
- Are any of the findings abnormal? If so, what is the next step?
- Was there any collaboration to provide ongoing, holistic care?
- Does the assessment include the woman and/or the baby? Remember that they are a dyad and what happens to one, affects the other so this should be considered in all documentation.
- What education or discussion was provided to the woman?
- What is the outcome of the assessment? Another appointment? Further investigations or procedures?
- Don't forget that health is multi-dimensional - while we focus a lot on physical health, there are other aspects such as psychosocial, spiritual etc which should be considered as they will be affected by physical health issues.
So, it is not merely a matter of 'ticking the boxes' but so much more. This is an important part of our students' learning so please help them to undertake their documentation in a way that promotes learning.
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