Understanding Nursing Documentation
- Discusses the importance and purposes of nursing documentation
- Outlines the legal issues and ethics involved in nursing documentation
- Describes nursing practise protocol in regards to documentation
- Discusses the key management issues of 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 essential 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.
Contents include
- Introduction
- Key terms
- Importance of documentation
- Purposes of documentation
- Leadership
- Legal issues
- Ethics
- Values
- Nursing practice
- Codes of conduct
- Standards of practice
- Holistic nursing practice
- Reflective nursing practice
- Praxis
- Management issues
- Language, jargon, and forms of expression
- Documentation not being performed
- Qualifications of nursing staff, levels of experience, and staff skills mix
- Attitudes of nursing staff to documentation and time management skills
- Government regulation
- Conclusion