Clinical Communication and Patient Identification Clinical Guideline

Version 5.0, approved 8 October 2024

The aims of the Clinical Communication and Patient Identification Clinical Guideline (PDF 749KB) are to:

  • improve patient safety by providing a structured framework that supports a consistent, best practice approach and reduces risk associated with clinical communication and patient identification within SA Health services, and between SA Health services and other health providers such as community services and residential care services.
  • ensure excellence in governance, practices and systems of clinical communication so that;
    • patient confidentiality and privacy requirements are respected
    • patients’ rights to be informed about their healthcare are met
    • patients’ and carers’ experience of care is enhanced through staff engaging with them, using kind and respectful communication, and providing person-centred care and the opportunity to ask questions and provide feedback
    • patients’ identity is systematically verified so that they receive the care that is intended for them, especially interventional invasive procedures
    • the requirements of National Safety and Quality Health Service Standards (NSQHSS) second edition are met
      • Refer to Appendix 1 – Actions that support effective clinical communication and safe patient care across the NSQHS Standards, Australian Commission on Safety and Quality in Healthcare (ACSQHC)
    • the requirements of health practitioners’ professional codes of practice, conduct and legislative requirements are met
    • staff experience and contribute towards a respectful workplace culture that values individual and team enabling shared learning, quality improvement and positive patient and carer outcomes
    • throughout all health care and transfers of care, staff handing over and also receiving responsibility for the ongoing care of a patient use;
      • robust verbal, written and electronic systems to provide comprehensive, timely, safe and effective communication that ensures the continuity, safety and quality of the patient’s care is maintained
      • effective systems to communicate critical information, risks and alerts
    • accurate, contemporaneous and comprehensive information is legibly documented in the healthcare record.

SA Health’s participation in the national, personally controlled My Health Record system will support these objectives.

The term patient is used throughout this document to represent all people in receipt of care and includes people who could be termed consumers or clients.

This Clinical Guideline must be read in conjunction with the accompanying toolkit.

Roles and responsibilities

This Clinical Guideline applies to all SA Health hospitals and services including, but not limited to, acute and sub-acute facilities, residential care services, ambulatory/community settings, SA Ambulance Service (SAAS) and Statewide Clinical Support Services (SCSS).