All Resources

Documenting Dementia Using Assessment To...ols
eChapter  16
Added: 17/06/2009
This chapter explores the use of a variety of different geriatric assessment tools and discusses their purposes. It focuses particularly on assessment tools designed for emotional, mental and behaviou...ral assessment.
American Experience, The
eChapter  14
Added: 17/06/2009
This chapter will provide a brief history of the transition to managed health care in the United States and outline the implications for Australian nurses, especially in relation to demands for increa...sed documentation practices. It will also motivate nurses to participate in improving health care delivery and community wellness and be willing to participate in the development and evaluation of global documentation tools to create a unified standard of care.
Writing It Down in the Bush
eChapter  11
Added: 17/06/2009
The demands of documentation may seem never-ending and almost impossible to manage at a small rural centre with very few scribes on hand. However, they are highly important records and need to be kept... up-to-date. This chapter provides useful suggestions for ensuring documentation standards are as good as, and perhaps better than, those of any city's multi-storey hospitals.
Health Records in the Home
eChapter  13
Added: 17/06/2009
This chapter explains the advantages and potential conflicts of using home health records. It demonstrates that the rightful focus of the home health setting is the client, the care provided and the c...arer. It shows that the aim of community nursing is to establish a partnership between nurse and client which empowers clients to participate fully in their own care.
End Matter
eChapter  End Matter
Added: 15/06/2009
This chapter contains the index to the Ausmed chapter series Nursing Documentation in Aged Care: A Guide to Practice. In addition to this useful reference, a glossary of key terms included in the is included and a post-series test that readers may find useful to check their knowledge.
Documenting Complementary Therapies
eChapter  8
Added: 15/06/2009
This chapter guides nurses in the documentation of an aged-care facility that utilises complementary therapies requires. This includes the planning stage where policies, procedures and protocols must considered as well as social profiling, the use of programs and consent, care plans and an evaluation stage.
eChapter  Prelims
Added: 15/06/2009
Prelims: Dedication, Acknowledgments,Foreword, Preface, Contents and About the Authors...
Nursing Care Plans
eChapter  4
Added: 15/06/2009
This chapter discusses the use of nursing-care plans (NCPs) in residential aged-care facilities. The purpose of NCPs is to provide individualised nursing care, but they have not always achieved their ...intended purpose. Nurses and their professional organisations will need to think strategically about nursing care and how it is planned and implemented.
Documenting Behaviour and Emotion
eChapter  7
Added: 15/06/2009
All nurses experience and observe the behaviour and emotion of those in their care throughout their work day. Whether these behaviours are expected or unexpected, nurses have a responsibility to them carefully and to record accurately what they have observed. It is essential that nurses recognise the nuances of human emotion and the behaviour that comes from the expression of that emotion. This chapter guides nurses on how to accurately assess and document emotion and behaviour.
Progress Notes
eChapter  5
Added: 15/06/2009
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.
Clinical Reasoning
eChapter  2
Added: 15/06/2009
Clinical reasoning is the process of reaching clinical conclusions through professional judgement, knowledge and experience. It also involves an understanding of the politics of clinical practice. in aged care need to understand the regulatory, political and social customs that dictate the care that is provided, when it is provided and who provides it. This chapter instructs nurses on how to understand Clinical Reasoning, its politics and its conflicts with documentation.
Professional Communication
eChapter  3
Added: 15/06/2009
Effective written and verbal communication in aged-care nursing demands a level of articulation that goes well beyond 'telling stories' about what has occurred in the care of a particular resident on ...a particular day. This chapter aims to instruct nurses on how to effectively communicate verbally and through documentation including the codes of professional practice.
Understanding Nursing Documentation
eChapter  1
Added: 15/06/2009
Nursing documentation is vitally important, and it is essential that all aged care facilities have a clear vision of their objectives and requirements with respect to this aspect of care. It is essent...ial that nurses follow the documentation requirements of the organisation in which they work. This chapter instructs nurses on the basics of nursing documentation, including the legal issues involved.
Documenting Pain Management
eChapter  9
Added: 15/06/2009
The International Association for the Study of Pain defines pain as 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such dam...age.' This chapter aims to convey correct pain documentation methods and the difficulties in communication that arise in aged-care.
Clinical Pathways
eChapter  6
Added: 15/06/2009
Many acute and subacute healthcare organisations have introduced evidence-based clinical pathways in response to the demands for cost reduction in an environment of increased consumer interest in care. The aim of such clinical pathways is to achieve quality outcomes within a specified time frame, using the resources that best meet the patients' needs.
Appendix 7: PEG Nutrition & Appendix 8: ...Wandering
eChapter  Appendix 7 & 8
Added: 10/06/2009
Nursing Documentation in Aged Care: Appendix 7 PEG Nutrition; Appendix 8: Wandering...
Appendix 5: Stomal Care & Appendix 6: Le...g Ulcer Management
eChapter  Appendix 5 & 6
Added: 10/06/2009
Nursing Documentation in Aged Care: Appendix 5: Stomal Care; Appendix 6: Leg Ulcer Management...
Appendix 3: Diabetes & Appendix 4: Nause...a
eChapter  Appendix 3 & 4
Added: 10/06/2009
Nursing Documentation in Aged Care: Appendix 3: Diabetes; Appendix 4: Nausea...
Subsequent Pregnancy
eChapter  5
Added: 10/06/2009
This chapter focuses on what to expect in a tentative pregnancy and the role a midwife plays in a subsequent pregnancy. It guides them through all stages from antenatal care to the postpartum stages a...nd explains all possible reactions form parents in all stages and how to deal with them.
Late Pregnancy Loss
eChapter  3
Added: 10/06/2009
This chapter explores the tragedy of late pregnancy loss and each situation which could possibly occur before, during and after the loss. Checklists, guidelines and examples are given to help give ins...ight to midwives and guide them through each stage with the parents.

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