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Progress Notes




  • Outlines the purposes and principles of documentation
  • Discusses the need of progress notes and the frequency of entries
  • Outlines methods of documenting progress notes
  • Outlines ethical and legal complications involved in documenting progress notes
  • Discusses the need for secure file management and electronic documentation

Effective communication in aged care is vital to the quality of resident care. Documentation is used to communicate details of the nursing care provided and to inform others of any significant events. There are many legal requirements involved in progress notes and it must always be remembered that a resident's notes represent a permanent written record of that person's nursing care and management. This chapter aims to guide nurses on how to effectively and securely document progress notes.


Contents include

  • Introduction
  • Purposes of documentation
  • Principles of effective documentation
  • The nature of progress notes
  • Responsibility for progress notes
  • Frequency and quality of entries
  • Common methods of documenting progress notes
    • Problem-oriented documentation
    • Focus charting
    • Charting by exception
    • Narrative progress notes
    • Integrated progress notes
  • Ethical and legal implications
    • Confidentiality
    • Subpoenaed notes
    • Avoidance of disciplinary/legal action
  • File management
  • Electronic documentation
  • Conclusion
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Author / Editor Biographies

Clinical Pathways
Jenni Ham is a registered nurse and midwife who holds a graduate diploma and a master's degree in health science. Since 1994, she has worked as a project manager and acting operations manager at the Collaborative Health Education & Research Centre (CHERC) of the Bendigo Health Care Group, Victoria, Australia. Jenni has extensive experience in the design and implementation of clinical pathways. Her research projects have included the design, implementation, and evaluation of clinical pathways in acute and rehabilitation settings and the design and implementation of clinical pathways in smaller ...
registered nurse and midwife who holds bachelor's and master's degrees in health science
Ann-Maree Conners is a registered nurse and midwife who holds bachelor's and master's degrees in health science. For the past five years, she has been the director of the Collaborative Health Education & Research Centre (CHERC) of Bendigo Health Care Group (Victoria, Australia) and has recently been appointed to the role of acting group director of nursing at the Bendigo Health Care Group. Ann-Maree has extensive experience in the development and coordination of education programs for registered nurses and has been involved in health research for a number of years. Her research interests h...
Angela Crombie is a registered nurse who holds a bachelor's degree in nursing and master's degree in health science. Angela also holds additional qualifications in psychiatric nursing and workplace assessment and training. She is employed as a research officer and nurse educator with the Collaborative Health Education & Research Centre (CHERC) of Bendigo Health Care Group (Victoria, Australia) specialising in research and education on aged-care issues. Angela has been involved in a number of research projects, many of which have included the design and development of care pathways in a variety...

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