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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
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Author / Editor Biographies

RN, B Ed, ADT & D, GradCert Ger, ACMS, GradCert IE & T, MRCNA and AIMM.
Program Co-coordinator for Health, Nursing & Aged Care programs at Kangan Batman TAFE. As well, she is the co- editor of the multi-author textbook "Nursing Documentation in Aged Care - a Guide to Practice". Gaye is passionate about aged care nursing as a professional specialty.
RN, RM, GradCert Ger, Dip (Education & Training), ADT & D and MRCNA
Christine Crofton is a registered nurse who has been involved in aged care for many years in a variety of roles - including senior management of aged-care facilities. She is currently a nurse educator who believes that older people must be valued, respected, and cared for in accordance with the highest professional standards. If this is to be achieved, Christine believes that documentation must be undertaken effectively and efficiently. If aged-care nurses are empowered and confident in their own abilities, positive resident outcomes and excellence in documentation will be assured.

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