Writing What We Do in the Community
This chapter will examine the documentation Australian community nurses are currently using, the trend towards combining documentation and client coding systems, an instance of community nursing infor...matics in the US and some legal issues associated with community nursing documentation.
Health Records in the Home
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.
American Experience, The
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.
Ageing, Dementia and Palliative Care
This chapter discusses communication and planning; the nurse's role as story-teller; whose voice will be heard?; problems with communication; and when 'enough is enough' in relation to palliative care......
Documenting the Intangible
This chapter discusses how to assess the spiritual needs of patients in order to become better equipped with providing care. It encourages nurses to listen to and empathise with patients in order that... they receive the spiritual care and guidance they require.
Designing a Form for Your Needs
This chapter offers some tips to help you design a better form; one that will do exactly what you want. Follow simple steps in order ensure that your forms are well-designed and easy to fill out......
Writing It Down in the Bush
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.
Documenting Behaviour and Emotion
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 obser...ve 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.
Documenting Pain Management
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.
Understanding Nursing Documentation
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.
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...