24355_AP_Nursing Documentation Book Nursing documentation is often perceived as a tiresome chore Although this perception of documentation is understandable, Nursing Documentation in Aged Care: A Guide to Practice is written from a different perspective The title of the book is carefully chosen All of the contributors to this book firmly believe that nursing documentation in aged care—if performed with pride and professionalism—is truly a guide to practice In striving for the highest standards of professionalism in all that they do, nurses are increasingly recognising that documentation is a wonderful opportunity to record and reflect upon all that is good in nursing In addition to their ethical and professional responsibilities, caring nurses are aware of the personal satisfaction to be gained from documenting their holistic and reflective nursing practice As another volume in Ausmed’s growing and popular ‘Guide to Practice’ series of textbooks and audiobooks, Nursing Documentation in Aged Care: A Guide to Practice is an essential text for all aged-care nurses who wish to enhance their documentation skills and deliver higher quality care to the elderly This book shows how nursing assessments, care plans, and progress notes can allow nurses to share their knowledge, observations, and skills—and thus make a crucial contribution to their own professional lives and to the quality of life of those in their care This is more than a ‘how-to-do-it’ workbook With contributions from a range of experts, this comprehensive evidence-based textbook explores the issues surrounding documentation and reveals the importance of professional communication within multidisciplinary teams Christine Crofton 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 Gaye Witney Gaye Witney is registered nurse who has had a passionate interest in aged care for longer than she wishes to admit! Her interest in documentation arose from her work with the Australian government on documentation validation and standards accreditation Gaye is now a nurse educator who encourages her students to take pride in being nurses—enthusing them to achieve high standards of documentation in their preparation of nursing assessments, nursing-care plans, and progress notes C M Y K C M Y K C M Y K Nursing Documentation in Aged Care A Guide to Practice DocumPrelimsFinalProofs.indd 26/03/2004 1:06:22 PM Other titles by Ausmed Publications Nurse Managers: A Guide to Practice Edited by Andrew Crowther Aged Care Nursing: A Guide to Practice Edited by Susan Carmody and Sue Forster Dementia Nursing: A Guide to Practice Edited by Rosalie Hudson Palliative Care Nursing: A Guide to Practice (2nd edn) Edited by Margaret O’Connor and Sanchia Aranda Lymphoedema Edited by Robert Twycross, Karen Jenns, and Jacquelyne Todd Communicating with Dying People and their Relatives Jean Lugton How Drugs Work Hugh McGavock Evidence-based Management Rosemary Stewart Communication and the Manager’s Job Annie Phillips Assertiveness and the Manager’s Job Annie Phillips Renal Nursing A Practical Approach Bobbee Terrill Ageing at Home Practical Approaches to Community Care Edited by Theresa Cluning Complementary Therapies in Nursing and Midwifery Edited by Pauline McCabe Keeping in Touch with someone who has Alzheimer’s Jane Crisp Geriatric Medicine a pocket guide for doctors, nurses, other health professionals and students (2nd edn) Len Gray, Michael Woodward, Ron Scholes, David Fonda & Wendy Busby Living Dying Caring life and death in a nursing home Rosalie Hudson & Jennifer Richmond Caring for People with Problem Behaviours (2nd edn) Bernadette Keane & Carolyn Dixon Practical Approaches to Infection Control in Residential Aged Care (2nd edn) Kevin Kendall Nursing the Person with Cancer a book for all nurses Edited by Gordon Poulton Caring for the Person with Faecal Incontinence a compassionate approach to management First edn authors: Karen Cavarra, Andrea Prentice & Cynthea Wellings Second edn author: Janette Williams Spirituality the heart of nursing Edited by Susan Ronaldson Nursing Documentation writing what we Edited by Jennifer Richmond Thinking Management focusing on people Edited by Jean Anderson All of these titles are available from the publisher: Ausmed Publications 277 Mt Alexander Road, Ascot Vale, Melbourne, Victoria 3032, Australia website: email: DocumPrelimsFinalProofs.indd 26/03/2004 1:06:22 PM Nursing Documentation in Aged Care A Guide to Practice Edited by Christine Crofton and Gaye Witney Foreword by Rosalie Hudson AUSMED PUBLICATIONS MELBOURNE – SAN FRANCISCO DocumPrelimsFinalProofs.indd 26/03/2004 1:06:23 PM Copyright ©Ausmed Publications Pty Ltd 2004 Ausmed Publications Pty Ltd Melbourne – San Francisco Melbourne office: 277 Mt Alexander Road Ascot Vale, Melbourne, Victoria 3032, Australia ABN 49 824 739 129 Telephone: + 61 9375 7311 Fax: + 61 9375 7299 email: website: San Francisco office: Martin P Hill Consulting 870 Market Street, Suite 720 San Francisco, CA 94102 USA Tel: 415-362-2331 Fax: 415-362-2333 Mobile: 415-309-2338 email: Although the Publisher has taken every care to ensure the accuracy of the professional, clinical, and technical components of this publication, it accepts no responsibility for any loss or damage suffered by any person as a result of following the procedures described or acting on information set out in this publication The Publisher reminds readers that the information in this publication is no substitute for individual medical and/or nursing assessment and treatment by professional staff Nursing Documentation in Aged Care: A Guide to Practice ISBN 0-9750445-4-0 First published by Ausmed Publications Pty Ltd, 2004 Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in, or introduced into a retrieval system or transmitted in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise) without the written permission of Ausmed Publications Requests and enquiries concerning reproduction and rights should be addressed to the Publisher at the above address National Library of Australia Cataloguing-in-Publication data Nursing documentation in aged care : a guide to practice Bibliography Includes index ISBN 9750445 Nursing records - Handbooks, manuals, etc Geriatric nursing - Handbooks, manuals, etc I Witney, Gaye II Crofton, Christine, 1947- 610.7365 Produced by Ginross Publishing Printed in Australia DocumPrelimsFinalProofs.indd 26/03/2004 1:06:23 PM Contents Dedication and Acknowledgments Foreword Preface About the Authors Chapter Understanding Nursing Documentation Christine Crofton and Gaye Witney Chapter Clinical Reasoning 19 Bart O’Brien Chapter Professional Communication 31 Christine Crofton and Gaye Witney Chapter Nursing Care Plans 45 Shirley Schulz-Robinson Chapter Progress Notes 63 Joanne Hope and Pamela Bell Chapter Clinical Pathways 79 Jenni Ham, Ann-Maree Conners, and Angela Crombie Chapter Documenting Behaviour and Emotion 97 Felicity Humble DocumPrelimsFinalProofs.indd 26/03/2004 1:06:24 PM vi Contents Chapter Documenting Complementary Therapies 109 Sue Forster Chapter Documenting Pain Management 123 Michael Cully Chapter 10 Documenting Restraint 137 Sue Forster Chapter 11 Incident Reports 151 Adrian Cross Chapter 12 Documenting Evaluative Criteria 169 Sue Forster Chapter 13 Documenting Staff Issues 181 Sue Forster Chapter 14 Effective Design for Documentation 193 John Collins Chapter 15 A Systems Model for Documentation 209 Christine Crofton and Gaye Witney Appendix Faecal Incontinence 249 Janette Williams Appendix Behavioural Management 255 Robyn Daskein Appendix Diabetes 261 Victoria Stevenson Appendix Nausea 267 Robyn Millership Appendix Stomal Care 273 Heather Hill Appendix Leg Ulcer Management 279 Sue Templeton Appendix PEG Nutrition 285 Patsy Montgomery Appendix Wandering 289 Beverly Smith References 293 Index 299 DocumPrelimsFinalProofs.indd 26/03/2004 1:06:24 PM vii Dedication This book is dedicated to aged-care nurses for their courage, resilience, and professionalism and to the elderly people who share so much of their lives with the nurses who care for them Acknowledgments To Jim, Jacinta, Robert, Eleanor, and Zoe, who have supported our passion for aged care, and who have encouraged us in all that we attempt To our family and friends, who have been there when needed To our industry colleagues for support and inspiration over the years and to the many skilled nurses who have influenced us during our careers To Cynthea and Ausmed Publications for having faith in us, and for making this book possible DocumPrelimsFinalProofs.indd 26/03/2004 1:06:24 PM DocumPrelimsFinalProofs.indd 26/03/2004 1:06:24 PM Foreword Rosalie Hudson Documentation has come alive! In Nursing Documentation in Aged Care: A Guide to Practice, the drudgery and monotony are taken out of an important aspect of nursing that has become, for many, a dreaded necessity Nurses will be inspired to take a fresh look at the many positive aspects of documentation and to enjoy the professional rewards of improved practice The issues are presented in ways that reinforce current good practice, encourage reflection on practice, and offer new ideas to guide improved practice The rewards of good documentation are to be found not only in professional pride, but also in creating more time for resident care The book is therefore timely in addressing the frustration expressed by many aged-care nurses: ‘How can we achieve a good balance between documentation and resident care?’ The various models of documentation described throughout this book will help to identify the unique details of each resident’s care What does this record convey about the care of this particular resident? Who is DocumPrelimsFinalProofs.indd 26/03/2004 1:06:24 PM 313 Index pain management (continued) numeric rating scales 119, 125–30, 201–2, 282 nutrition 130 objectivity 201 osteoarthritis 131, 132 peripheral vascular disease 131, 132 peripheral neuropathies 131, 132 procedures for pain documentation 134–6 professionalism 134 quality control 136 reliability 125, 130 signatures and designations 135 sleep patterns 125, 127, 130, 133 social issues 125, 131, 133, 135 unrecognised pain 130–2 validity 125, 130 values and value judgments 134, 136 wandering 131 Parkinson’s disease 46 pathways see clinical pathways PEG nutrition 285–8 performance appraisal 181, 182, 183, 187, 188, 191 peripheral vascular disease 131, 132 peripheral neuropathies 131, 132 permanency of documentation 5, 63 physiotherapy assessment 12, 87, 252, 262 policies, procedures, and protocols clinical pathways 80, 84, 85, 91 92, 93, 94 clinical reasoning 29 complementary therapies 110–112, 113, 121 incident reports 145, 152, 153, 154, 155, 156, 157, 164, 165 nursing-care plans 45, 47 occupational health and safety 164 pain management 134–6 professional communication 40 progress notes 63, 66, 67, 76 restraint 138–41, 143–4, 145, 146 systems model and 211, 212, 213, 218, 226–8, 234 DocumEndmatterThirdPages.indd 21 policies, procedures, and protocols (continued) understanding documentation 8, 10, 14, 16 political factors 8, 19, 24, 27–8 privacy see confidentiality and privacy problem-intervention statements 48 problem-oriented documentation 68–9, 70 procedures see policies, procedures, and protocols professional communication 31–43 see also professionalism accountability 43 accuracy 33 advocacy 33 analysis and 32 assessing the system 36–7, 38–41, 43 attitudes of staff 35, 36, 37–9, 40, 41, 42, 43 auditing and 32, 39, 43 coaching 37–8 clinical reasoning and 23, 24, 25 codes of ethics 32–3, 43 codes of professional practice 32, 33–4, 43 education and 30, 31, 40 effective documentation and nursing 31, 32, 35, 36, 40, 42, 43 ethics 32–3, 43 evaluation 40, 41, 42 evidence-based practice 39 feedback 38–9 funding and 31, 35 gap analysis 39–41 holistic nursing 33, 34–5 implementation 35, 36, 39, 41, 42, 43 individualising care 38 initiative and innovation 34, 41, 42 leadership 34, 40, 43 legal requirements and 32 management and organisational issues 32, 33, 34, 35–8, 39–41, 42, 43 nursing-care plans and 48, 57 professional practice 32, 33–4, 43 progress notes 63, 64, 73 quality control 39–41 28/03/2004 11:17:00 AM 314 Index professional communication (continued) reflection and 32 regulatory requirements 40, 43 research and 32, 43 risk management 41–2 systems model and 32, 33, 34, 35, 38–40, 43, 227 timeliness 34 understanding documentation 3, 11 validity 32 values and value judgments 32, 37, 38 professionalism see also professional communication behaviour and emotion 98, 105, 107, 108 clinical pathways 79, 81, 85, 90, 94 clinical reasoning and 19, 25, 27, 28, 29 codes of conduct codes of ethics 32–3, 43 codes of professional practice 32, 33–4, 43, 59 communication see professional communication complementary therapies 111, 115, 116 design of documentation 208 evaluation 40, 41, 42, 175 incident reports 153, 154, 157 multidisciplinary teams 31, 33, 34, 40 nursing-care plans and 45, 47–8, 50, 51, 54, 55, 58, 59, 60, 238 pain management 134 professional practice 32, 33–4, 43 progress notes 63, 64, 66, 67, 68, 73, 77 restraint 138, 141, 142 staff issues 188, 191 standards of practice 2, 9, 17 systems model 209, 210, 213, 215, 216, 218, 222, 223, 235, 236, 237, 238, 239, 244 understanding documentation 2, 5, 7, 8, 9, 10, 13, 14 programs activities 259 behavioural modification 170, 257, 258, 259 DocumEndmatterThirdPages.indd 22 programs (continued) complementary therapies 110, 113, 114– 115, 119 continence 256 diversional therapist 257 educational 11, 64, 92, 121, 148, 190, 234–6 employee-assistance program 186, 188 exercise 252 faecal incontinence 252 incentive program 187 leg ulcers 280 occupational health and safety 164 quality improvement 10 restraint 148 volunteer program 259 word-processing 197 progress notes 63–77 abbreviations 65, 74 access 66, 71, 73, 74, 76 accountability 63, 67 accuracy 64, 65, 67, 68, 71, 73, 74, 75, 77 archiving 75 assessments (nursing process) 63, 64, 69, 70, 72, 77 audits 64 behaviour and emotion 77 best practice 60, 66 blank spaces 65 charting-by-exception 66, 67, 68, 70–1, 72 communication 63, 64, 73 confidentiality 74, 75–6 consent 74 continuity of care 64, 66, 67, 68, 73 corrections 65 ‘DAR’ charting method 70 dates and time 65 education 64, 69 effective documentation and nursing 63, 64, 65, 76 electronic documentation 76 emotional aspects 77 ethical issues 67, 74–5 evaluation 69 28/03/2004 11:17:00 AM 315 Index progress notes (continued) file management 75–6 frequency and quality 66–8 focus charting 68, 70 funding 63, 64, 73 holistic nursing care 71 incident reports 74–5 individualising care 71, 72 integrated progress notes 68, 70, 73 interventions 67, 70, 71 language and jargon 65 legal requirements 63, 64, 66, 67, 68, 74–5, 76 legibility 65, 74 management and organisational issues 63, 64, 66, 70, 74, 75–6 medication 71 multidisciplinary teams 68, 69, 71, 72 narrative progress notes 68, 70, 71–3 nature of 66, 76–7 nursing-care plans and 67, 71, 72, 77 nursing interventions 67 objectivity 69 principles of documentation 65 problem-oriented documentation 68–9, 70 professionalism 63, 64, 66, 67, 68, 73, 77 purposes of documentation 63–4 quality improvement 63, 64, 65 referrals 69 research 76 resident-centred care 63 responsibility for 66 signatures and designation 65, 74–5, 76 ‘SOAP’ charting method 68 social issues 77 source-oriented health records 71–3 spiritual aspects 77 standards of practice 63 storage 66, 75–6 systems model 212, 218, 238–9 timeliness 67–8, 75 validity 76 values and value judgments 74 protocols see policies, procedures, and protocols DocumEndmatterThirdPages.indd 23 publishing 11, 203, 212, 242–4 pulse rate 119, 175, 177, 178, 283 qualifications of staff see also education; experience of nurses clinical pathways 89 complementary therapies 111, 112, 117, 121 credentialling of staff 182, 183, 190–1 nursing-care plans 49, 50, 53, 57, 60, 61 restraint 148 staff issues 187, 190 understanding documentation 10, 15, 16 quality control and improvement behaviour and emotion 97 clinical pathways 79, 82, 83, 84, 85, 86, 90, 94 clinical reasoning 26, 29, 30 complementary therapies 115, 122 evaluation and evaluative criteria 180 incident reports 164 nursing-care plans and 47, 60 pain management 136 professional communication and 39–41 programs 10 progress notes and 63, 64, 65 systems model and 211, 212, 213, 224–6, 234, 244 understanding documentation 3, 7, 9, 10 reasoning see clinical reasoning records see also clinical paths; nursing-care plans; progress notes accessibility 7, 23, 58, 59, 71, 73, 74, 76, 90, 155 accuracy of see accuracy of documentation’ behaviour and emotion 97, 101, 102, 103, 107, 225 clinical pathways 89 complementary therapies 110, 113, 115, 116, 118, 121 design of documentation 193, 200, 201, 202, 204, 206, 208 destruction of 28/03/2004 11:17:01 AM 316 Index records (continued) diabetes 263 discipline 189 educational 110, 113, 121, 138, 139, 148, 188, 189, 190 electronic 182 evaluation 171, 172, 176, 177, 180, 242 health 116, 143, 172, 223 incident reports 151, 154, 157, 158, 159, 161, 165, 166, 167 leg ulcer 281 nausea 268, 271 nursing-care plan 238 pain management 127, 131, 132, 134 permanency of personnel 189 progress notes 75–6, 77, 238, 242 resident 77, 131, 132, 172, 223 responsibility for 66 restraint 138, 139, 143, 145, 148 staff appraisals 188 staff issues 184, 185, 188, 189, 190, 191 staff selection 184, 185 stomal care 287, 288 storage of 6, 66, 75–6 systems model 210, 213, 214, 216, 222, 223, 233, 238, 242 referrals clinical pathways 83, 85, 86–7 complementary therapies 114 incident reports 156 leg ulcers 283 nursing-care paths 58 nursing-care plans 58 progress notes 69 ‘SOAP’ system and 69 stomal management 288 reflective nursing practice 13, 14, 17, 32, 214, 215, 216, 234, 258 regulatory requirements clinical reasoning and 19, 26, 27, 28, 29, 30 destruction of records incident reports 156 management issues 15, 17 DocumEndmatterThirdPages.indd 24 regulatory requirements (continued) professional communication and 40, 43 restraint 138 staff issues 188 systems model 211, 212, 213, 221–4, 227, 234 understanding documentation 6, 15, 17 reliability behaviour and emotion 98 clinical pathways 87 evaluation and evaluative criteria 170, 171, 173, 175, 176, 177 nurses’ attitudes 33, 257, 258 pain management 125, 130 systems model 232, 238 research clinical pathways 92 complementary therapies 120 evaluation and evaluative criteria 172 incident reports 161 professional communication and 32, 43 progress notes 76 restraint 147 signatures and designations 120 systems model 211, 212, 213, 216, 218, 228–34, 235, 237, 238, 243 understanding documentation 3, 10 resident-centred care see also individualising care clinical pathways 80, 82, 83, 85, 86, 88–9, 94 clinical reasoning 29, 30 complementary therapies 111, 115, 122 evaluation 178, 179 nursing-care plans 50, 51–7, 59 progress notes 63 restraint 147 systems model 213, 216, 220, 241 respiratory rate 175, 177 restraint 137–49 accountability 139, 140 accreditation 141 accuracy 149 anti-discrimination rights 139, 140–1 28/03/2004 11:17:01 AM 317 Index restraint (continued) appeal rights 139, 140–1 assessments (nursing process) 138, 139, 141–2, 145 auditing 145, 147 authority to restrain 145 behaviour 142, 145 benchmarking 147 building safety 147 care plans 138, 144–5, 146 chemical restraint 137 cognitive state 143, 147 comfort activities 145 communication 142 consents and authorities 138, 142–4, 145 dates and time 143, 145 depression 142 education 138, 139, 147–8 effective documentation and nursing 147, 148 equipment safety 147 ethics 138, 140–1, 147 evaluation 138, 139, 145, 146, 147, 148 falls 142 grievance rights 139, 140–1 hazard-identification forms 145 holistic nursing practice 138 implementation 139, 141 incident reports 145 interventions 143, 144, 147 legal issues 138, 140–1, 142, 143, 144, 149 management and organisational issues 138, 139, 140, 141, 142, 143, 145, 147 medication 137, 139, 145 mini-mental 142 mission statement 138 mobility 142, 144, 146 multidisciplinary teams 138 nurse/resident ratios 144 nurse registration bodies 138, 141 objectivity 147, 148 occupational health and safety 139, 140, 141 physical restraint 137 DocumEndmatterThirdPages.indd 25 restraint (continued) policies, procedures, and protocols 138– 41, 143–4, 145, 146 professionalism 138, 141, 142 protective assistance 138, 148 qualifications of staff 148 regulatory authorities 138 research 147 resident-centred care 147 resident profile 142 resources 139–40 restraint review form 145 risk assessment 141, 144, 147, 148 signatures 142–3 sleep patterns 142, 144 social issues 147 special senses 142 vision statement 138 risk management clinical pathways 87 diabetes 265 falls risk 87, 142 injury risk 46 leg ulcers 282 manual-handling risk assessment 12 occupational health and safety 141, 159 PEG nutrition 182 professional communication and 41–2, 43 restraint 141, 144, 147, 148 risk assessment 12, 41–2, 87, 112, 141, 142, 143, 147, 148, 159, 240 systems model 215, 216, 236, 237, 239 understanding documentation 12 safety risk assessment 12 sensory assessments 12, 114, 123, 142, 155, 177 sexual health 12, 26 signatures and designations complementary therapies 110, 114, 116– 117, 120 design of documentation 206–7 pain management 135 progress notes 65, 74–5, 76 28/03/2004 11:17:01 AM 318 Index signatures and designations (continued) research 120 restraint 142–3 systems model 222 understanding documentation 5, skills-acquisition theory 19, 21–2 skin assessment 12, 114, 199, 256 sleep patterns assessments (nursing process) 12 114, 142, 256, 265 behaviour and emotion 103, 104 complementary therapies 114 incident reports 155 pain management 125, 127, 130, 133 restraint 142, 144 understanding documentation 12 ‘SOAP’ charting method 68 ‘SOAPIE’ system 48 social issues assessments (nursing process) 110, 112, 113–14, 199, 257, 258 behaviour and emotion 98, 101, 103 clinical pathways 86 clinical reasoning 19, 24 complementary therapies 110, 112–14, 115, 120 incident reports 156 nursing-care plans 46, 52, 53, 54, 56, 58, 60 pain management 125, 131, 133, 135 progress notes 77 restraint 147 understanding documentation 8, 12 source-oriented health records 71–3 special senses assessment 114, 142 speech therapist assessment 288 spiritual issues 8, 12, 77, 113, 155 staff issues, documentation of 181–91 see also nurses and nursing; experience of nurses; qualifications of staff absenteeism 186 accountability 187 accuracy 182, 185, 190, 191 advertisements 183, 185 affirmative action 181 DocumEndmatterThirdPages.indd 26 staff issues, documentation of (continued) anti-discrimination 181, 187 appeals 184, 185 attrition of staff 182, 183, 186–8, 191 complaints 182, 189 counselling 187 credentialling of staff 182, 183, 190–1 discipline of staff 181, 182 183, 189–90, 191 duty statement 183, 185 education 187, 189, 190 electronic documentation 182 employee assistance program 186 employment contract 185, 186, 187, 188 equal opportunity 181 feedback 185, 187 formative evaluation 188 grievances 190 handbook 184, 186 human-resource management 181, 191 information package 184, 185 interviews 184 job analysis 182, 185 job sharing 187 key selection criteria 183, 184, 185, 188 legal aspects 184, 185, 189, 190, 191 morale 187 occupational health and safety 181 performance appraisal 181, 182, 183, 187, 188, 191 position description 183, 185 recruiting staff 181 responsibility 188 retaining staff 182, 183, 186, 187, 191 selecting staff 181, 182–6, 191 social justice 182 staff-satisfaction surveys 188 summative evaluation 188 staff/resident ratios 13, 50, 57, 144 staff-satisfaction surveys 188 standards of practice 2, 9, 17 stomal care 273–7 subjectivity 48, 69, 169, 170 171, 173– 5, 188, 201 28/03/2004 11:17:01 AM 319 Index summative evaluation techniques 170, 171, 172, 173, 188 ‘sundowner syndrome’ 20 systems model for documentation 209–44 abbreviations 222 accessibility 216, 217, 222, 223, 228, 231, 238, 244 accountability 216, 220 adult learning 236 assessment of the model 212, 239–42 assessments (nursing process) 212, 214, 218, 236–8, 242 attitudes of nurses 209, 210, 212, 213, 227–8, 234, 235 auditing 212, 224, 237, 238, 239–40, 241–2 benchmarking 212, 214, 235, 240 best practice 211, 213, 214, 228, 235, 239, 240, 244 career options 214, 215, 216 change agents 215 Cinahl information 219 clinical governance 211–15, 216, 233 Cochrane Collaboration 217, 218 code of ethics 223 cognitive function 235 complaints 216, 240 confidentiality 222–3 corrections 222 critical appraisal 217, 218, 232, 234–5 documentation essentials 212, 236–9 duty of care 222 education 212, 215, 220, 232, 234–6, 237, 239, 240 effectiveness of documentation 214 electronic documentation 217 ethics 219, 223, 227 evaluation (of documentation model) 217, 218, 229, 232, 233, 234, 239 evaluation (nursing process) 214, 237, 242 evidence-based practice 211, 212, 213, 214, 215–19, 233, 235 feedback 239 funding 211, 244 DocumEndmatterThirdPages.indd 27 systems model for documentation (continued) handbooks 218, 230 holistic practice 210, 236 implementation 211, 213, 216, 218, 220, 224, 228, 236, 237 innovation 216 Internet 183, 222, 231, 232, 233 interventions 241 jargon 222 leadership 216, 220, 224 learning from experiences 214 legal aspects 222, 223 legibility 222 management issues 209–10, 211, 216, 219–21, 226–8 Medline 219 mission statement 220 multidisciplinary teams 219, 221, 237, 244 nursing-care plans 212, 214, 218, 238 nursing team 215 objectivity 217, 222, 233 occupational health and safety 223 philosophy of documentation 211, 212, 213, 219–21, 233 policies and procedures 211, 212, 213, 218, 226–8, 234 preparatory work 211–34 professional communication 32, 33, 34, 35, 38–40, 43, 227 professional development 215, 216 professionalism 209, 210, 213, 215, 216, 218, 222, 223, 235, 236, 237, 238, 239, 244 progress notes 212, 218, 238–9 publishing 212, 242–4 quality system 211, 212, 213, 224–6, 234, 244 reflection 214, 215, 216, 234 regulatory compliance 211, 212, 213, 221–4, 227, 234 reliability 232, 238 research 211, 212, 213, 216, 218, 228–34, 235, 237, 238, 243 28/03/2004 11:17:01 AM 320 Index systems model for documentation (continued) resident-centred care 213, 216, 220, 241 risk management 215, 216, 236, 237, 239 signatures 222 storage 224 understanding documentation and validity 217, 226, 237, 238 values and value judgments 216, 219–20, 228, 236 verbal culture of nurses 222 vision statement 220 teams see multidisciplinary teams temperature 48, 53, 175, 177, 200 timeliness and time management behaviour and emotion 107 clinical pathways 84 professional communication and 34 progress notes 67–8, 75 understanding documentation 5, 15 typefaces 197, 199–200 understanding documentation 1–17 abbreviations 6, 15 access accountability 13, 16 accuracy 3, 5, assessments (nursing process) 12 attitudes of staff 4, 15, 16–17 auditing 10, 11 benchmark standards 9, 10–11 best practice 5, 10, 13 blank spaces care plans codes of conduct cognitive state 12 communication 3, 11 confidentiality 5, continuity of care corrections data analysis 11 data collection 11 dates and time 5, DocumEndmatterThirdPages.indd 28 understanding documentation (continued) definition of documentation designation destruction of records documentation not performed 15 duty of care education 2, 3, 8, 11, 14, 16 ethics 2, 6–7, 8, 17 evaluation 10, 11 evidence-based practice 5, 10 food intake 12 funding 1, 3, 4, 17 government regulation 15, 17 holistic nursing practice 9, 12, 17 implementation 3, 14 importance of documentation incident reports 6, indicators 10 individualising care key aspects 10 key terms language and jargon 15 leadership 2, 4–5, 10, 11, 17 legal issues 3, 5–6, 17 legibility management and organisational issues 1–2, 3, 4, 7, 8, 9, 11, 13, 14–17 nursing-care plans 9, 15 nursing practice 9–14 management issues 14–17 multidisciplinary teams 2, 5, 6, 7, 8, 10, 11, 15, 16 objectivity permanency praxis 13–14 professionalism 2, 3, 5, 7, 8, 9, 10, 11, 13, 14 purposes of documentation qualifications of staff 10, 15, 16 quality control and improvement 3, 7, 9, 10 reflective nursing practice 13, 17 research 3, 10 responsibility 6, 8, 14 28/03/2004 11:17:01 AM 321 Index understanding documentation (continued) scope of practice 10, 15 signatures and designations 5, sleep patterns 12 social issues 8, 12 spiritual issues 8, 12 standards of practice 2, 9, 17 storage system of time management 5, 15 validity 11 values and value judgments 2, 7–8, 12, 17 urinalysis 177, 178 urinary assessments 178, 269 urinary incontinence 274 urinary stoma 276 urinary tract infection 52, 53, 170, 269 variance and variance analysis 80, 82, 83, 84, 85, 93, 94, 175, 176 verbal tradition of nurses 47, 49 visibility of nurses’ work 47, 59 vision statements 111, 138, 152, 220 visual assessment 12 volunteer programs 259 wandering 131, 289–92 weight 175, 176, 178, 273, 286 word-processing programs 197 wound assessment 12, 114, 119, 177, 178, 277, 279–83, 288 validity clinical pathways 81, 87 clinical reasoning 21, 23, 27 complaints 189 complementary therapies 120 consent 115, 116, 142, 143, 144 credentialling 191 evaluation 170, 171, 173, 175, 176, 177 pain management 125, 130 professional communication 32 progress notes 76 staff-satisfaction surveys 188 systems model 217, 226, 237, 238 understanding documentation 11 values and value judgments clinical pathways 81 evaluation 169, 174–5 nursing-care plans 49, 58 pain management 134, 136 professional communication 32, 37, 38 progress notes 74 systems model for documentation 216, 219–20, 228, 236 understanding documentation 2, 7–8, 12, 17 DocumEndmatterThirdPages.indd 29 28/03/2004 11:17:02 AM DocumEndmatterThirdPages.indd 30 28/03/2004 11:17:02 AM DocumEndmatterThirdPages.indd 31 28/03/2004 11:17:02 AM DocumEndmatterThirdPages.indd 32 28/03/2004 11:17:02 AM From the extensive list of books from Ausmed Publications, the publisher especially recommends the following as being of interest to readers of Nursing Documentation in Aged Care: A Guide to Practice All of these titles are available from the publisher: Ausmed Publications, 277 Mt Alexander Road, Ascot Vale, Melbourne, Victoria 3032, Australia website: ; email: Aged Care Nursing: A Guide to Practice Edited by Susan Carmody and Sue Forster The aged population has grown markedly throughout the world, but there is a shortage of experienced nurses with expertise in the holistic care of the elderly This book is written to inspire and empower such nurses Aged Care Nursing: A Guide to Practice is written by clinicians for clinicians The inclusion of evidence-based and outcome-based practices throughout the book ensures that all readers, be they novices or experts, will have a reliable and comprehensive reference to guide their practice Each author is a recognised expert in his or her subject area, and all present their topics with a focus that is practical, rather than academic Available as textbook alone or as audiobook–textbook package Dementia Nursing: A Guide to Practice Edited by Rosalie Hudson Dementia is one of the major health problems of our ageing society and dementia nursing is one of the most important and highly skilled of nursing specialities As another volume in Ausmed’s growing ‘Guide to Practice’ series, this is the definitive textbook on dementia nursing The chapters are written primarily by nurses for nurses But dementia nursing is essentially an exercise in teamwork, and valuable contributions and insights are offered by other health professionals, carers, artists, and relatives from a variety of backgrounds and countries The result is a comprehensive international volume on all aspects of dementia nursing Available as textbook alone or as audiobook–textbook package Practical Approaches to Infection Control in Residential Aged Care Kevin Kendall For those who work in aged care, this book presents an exceptional opportunity to learn how to protect yourselves, other staff members, and residents from the ever-present dangers of infection The author believes that infection control polices should be coffee-stained and dog-eared, not shelved and clean! DocumEndmatterThirdPages.indd 33 28/03/2004 11:17:02 AM From the extensive list of books from Ausmed Publications, the publisher especially recommends the following as being of interest to readers of Nursing Documentation in Aged Care: A Guide to Practice All of these titles are available from the publisher: Ausmed Publications, 277 Mt Alexander Road, Ascot Vale, Melbourne, Victoria 3032, Australia website: ; email: Palliative Care Nursing: A Guide to Practice (2nd edn) Edited by Margaret O’Connor and Sanchia Aranda This second edition of Palliative Care Nursing has been totally revised, rewritten, and redesigned The result is a comprehensive handsome volume that builds upon the successful formula of the popular first edition All nurses and other health professionals with an interest in this vital subject will welcome this new edition as an essential addition to their libraries This is the definitive textbook on palliative-care nursing Nurse Managers: A Guide to Practice Edited by Andrew Crowther This book addresses the core issues associated with nurse management, and is thus an essential primary text for all nurses as they develop their managerial skills This book is an innovative and practical text that fulfils a previously unmet need It provides the evidence-based, practical advice that nurse managers require to undertake their important role with growing confidence and expertise The book covers such issues as promotion, leadership and motivation, moral management, dealing with unhelpful staff, occupational health and safety, budgets, information technology, and many other vital issues in modern nurse management In all these areas, the reader is offered a range of solutions and coping strategies for the issues that confront nurse managers every day Available as textbook alone or as audiobook–textbook package Keeping in Touch—with someone who has Alzheimer’s Jane Crisp This book is a resource for ideas about how you, the family member or the professional carer can celebrate and value the lives of those who are affected by dementia It contains practical ideas for daily living activities and communications DocumEndmatterThirdPages.indd 34 28/03/2004 11:17:02 AM 24355_AP_Nursing Documentation Book Nursing documentation is often perceived as a tiresome chore Although this perception of documentation is understandable, Nursing Documentation in Aged Care: A Guide to Practice is written from a different perspective The title of the book is carefully chosen All of the contributors to this book firmly believe that nursing documentation in aged care—if performed with pride and professionalism—is truly a guide to practice In striving for the highest standards of professionalism in all that they do, nurses are increasingly recognising that documentation is a wonderful opportunity to record and reflect upon all that is good in nursing In addition to their ethical and professional responsibilities, caring nurses are aware of the personal satisfaction to be gained from documenting their holistic and reflective nursing practice As another volume in Ausmed’s growing and popular ‘Guide to Practice’ series of textbooks and audiobooks, Nursing Documentation in Aged Care: A Guide to Practice is an essential text for all aged-care nurses who wish to enhance their documentation skills and deliver higher quality care to the elderly This book shows how nursing assessments, care plans, and progress notes can allow nurses to share their knowledge, observations, and skills—and thus make a crucial contribution to their own professional lives and to the quality of life of those in their care This is more than a ‘how-to-do-it’ workbook With contributions from a range of experts, this comprehensive evidence-based textbook explores the issues surrounding documentation and reveals the importance of professional communication within multidisciplinary teams Christine Crofton 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 Gaye Witney Gaye Witney is registered nurse who has had a passionate interest in aged care for longer than she wishes to admit! Her interest in documentation arose from her work with the Australian government on documentation validation and standards accreditation Gaye is now a nurse educator who encourages her students to take pride in being nurses—enthusing them to achieve high standards of documentation in their preparation of nursing assessments, nursing-care plans, and progress notes C M Y K C M Y K C M Y K ... National Library of Australia Cataloguing -in- Publication data Nursing documentation in aged care : a guide to practice Bibliography Includes index ISBN 9750445 Nursing records - Handbooks, manuals,... hospitals and aged- care facilities Adrian is now a lecturer in aged- services management and occupational health and safety at Victoria University and Kangan Batman TAFE (Melbourne, Australia) Pamela... team collects and organises data for each indicator Auditing Benchmarking Data analysis Team analyses data, identifies patterns, and determines if a problem exists Auditing Benchmarking Taking action