Library Home eChapter Writing It Down in the Bush

Writing It Down in the Bush

  • Includes tips on keeping case history notes up-to-date and relevant
  • Discuses the importance of confidentiality with regard to patient records
  • Focuses on auditing as a means of identifying areas of documentation that have improved, and those that need more work

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.

Contents include

  • Statistics Case
  • History Notes
    • Content Of Notes
    • Access To Files And Confidentiality
    • Client Information And Referral Record (Cirr)
  • Community Documentation
    • Deaths
    • Health Promotion Documentation
    • Early Detection
  • Auditing And Planning
    • Year/Service Plan
    • Audits
  • Policies, Protocols And Procedures
    • Orientation Directory And Map
  • In Summary
  • References
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Author / Editor Biographies

RN, BAppSc (Nursing), GradDip (Arts/Psychology) and MRCNA.
Mary Filmer is charge nurse of the small Bush Nursing Centre at Cann River in the far eastern corner of Victoria. She has been a remote-area nurse for over 25 years and is a keen advocate for home-based palliative care, including psychological support for clients and their carers. Mary certainly understands the value of the written word. Most of her education-secondary, vocational and short courses from painting to palliative care-has been gained by distance education. Mary is the wife of a dairy farmer, mother of three and also a grandmother. Her other interests include arts and crafts, and w...

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