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 is the process of reaching clinical conclusions through professional judgement, knowledge and experience. It also involves an understanding of the politics of clinical practice. Nur...ses 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.
Documenting Complementary Therapies
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 ...be considered as well as social profiling, the use of programs and consent, care plans and an evaluation stage.
Prelims: Dedication, Acknowledgments,Foreword, Preface, Contents and About the Authors...
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 heal...th 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.
Nursing Care Plans
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.
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.
eChapter End Matter
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 seri...es is included and a post-series test that readers may find useful to check their knowledge.
Appendix 5: Stomal Care & Appendix 6: Le...g Ulcer Management
eChapter Appendix 5 & 6
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
Nursing Documentation in Aged Care: Appendix 3: Diabetes; Appendix 4: Nausea...
Restraint can be defined as the use of any methodology or apparatus that controls a person's choice to move freely and which cannot be easily removed by that person. It is important to correctly docum...ent any form of restraint, both physical and chemical. This chapter discusses the use of restraint in an aged care facility and its correct documentation.
The reporting of incidents is a vitally important aspect of nursing documentation. Proper incident reporting makes a significant contribution to high standards of care for residents and improved occup...ational health and safety for staff. This chapter guides nurses on how to accurately report an incidence and to ensure a higher level of safety for both staff and residents in an aged care facility.
Documenting Evaluative Criteria
Evaluative criteria are measurement parameters that are based upon an accepted rule, standard or principle. All phases of care need to be clearly documented and evaluated. If the documentary evidence ...of evaluation is inadequate, all future care actions are in jeopardy of being unsuitable or even potentially hazardous. This chapter guides nurses on how to accurately use the parameters of evaluation and correctly document it.
Effective Design for Documentation
This chapter offers practical advice on the design of effective forms for nursing documentation. Well designed forms are easier to use, but before designing a completely new form nurses should conside...r whether they are able to adapt to an existing one. The suggestions in this chapter will help nurses to design forms that best suit their purposes.
Appendices 1-5: The Midwife and the Bere...aved Family
These appendices outline numerous topics in which the midwife can offer further support not only to family members but also to themselves. It also clarifies information about different cultures and re...ligions...These appendices outline numerous topics in which the midwife can offer further support not only to family members but also to themselves. It clarifies information about different cultures and religions and offers guidelines and steps to take to offer the best possible care.
Late Pregnancy Loss
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.
Appendix 1: Faecal Incontinence & Append...ix 2: Behavioural Management
eChapter Appendix 1 & 2
Nursing Documentation in Aged Care: Appendix 1: Faecal Incontinence; Appendix 2: Behavioural Management...
Mid Trimester Loss
This chapter provides insight into the different choices parents can make and their outcomes. Through case studies, midwives are guided through how they should act and not act. Clinical management des...criptions are also provided for varied decisions and throughout the entire chapter midwives are advised on how to inform parents for even the worst news.
eChapter End Matter
This chapter contains the index to the Ausmed chapter series The Midwife and the Bereaved Family. In addition to this useful reference, a glossary of key terms included in the series is included and a... post-series test that readers may find useful to check their knowledge.