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A Systems Model for Documentation




  • Outlines the preparatory work needed before establishing a system of documentation in a facility
  • Highlights the need for an educational program to establish positive attitudes to documentation
  • Outlines the essential tools needed for effective documentation
  • Highlights the importance of sharing documentation experiences with colleagues in the nursing industry

This final chapter takes a broader view of the subject in presenting a systems model for professional nursing documentation in aged care. In presenting a systematic overview of documentation, the chapter draws together many of the topics considered in earlier chapters and presents them in one coherent model. The model presented here puts many of the topics of earlier chapters into an overall context.


Contents include

  • Introduction
  • Preparatory work
    • Clinical governance and documentation
    • Evidence-based practice
    • Philosophy
    • Regulatory compliance
    • Quality systems
    • Policies and procedures
    • Research
    • Summary of preparatory work
  • Education
  • Documentation essentials
    • Assessment and nursing diagnosis using nursing-assessment tools
    • Nursing-care plans
    • Progress notes
    • Assessment
    • Auditing
    • Benchmarking
  • Publishing
    • Journal articles
    • Conference presentation
  • Conclusion
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Author / Editor Biographies

RN, B Ed, ADT & D, GradCert Ger, ACMS, GradCert IE & T, MRCNA and AIMM.
Program Co-coordinator for Health, Nursing & Aged Care programs at Kangan Batman TAFE. As well, she is the co- editor of the multi-author textbook "Nursing Documentation in Aged Care - a Guide to Practice". Gaye is passionate about aged care nursing as a professional specialty.
RN, RM, GradCert Ger, Dip (Education & Training), ADT & D and MRCNA
Christine Crofton is a registered nurse who has been involved in aged care for many years in a variety of roles - including senior management of aged-care facilities. She is currently a nurse educator who believes that older people must be valued, respected, and cared for in accordance with the highest professional standards. If this is to be achieved, Christine believes that documentation must be undertaken effectively and efficiently. If aged-care nurses are empowered and confident in their own abilities, positive resident outcomes and excellence in documentation will be assured.

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