Documentation Review: Developing a New Record

Chapter 17: Documentation Review - Developing a New Record

Overview:

• Includes a flow chart summarising the process for developing new client records

Description:

This chapter briefly summarises the process involved in change to existing nursing care records when there is change in the way nursing care is delivered.

Topics:

• Process for developing new client records
• References

Speakers / Authors:

Jenny Pilgrim RN, RM, B App Sc (Adv Nurs Ed), MRCNA
Jenny is a nurse educator with Healthlinks Education and Training Service, Royal District Nursing Service, Melbourne. A community nursing clinician and educator for the last seven years, Jenny has a long-standing interest in community clinical issues, especially chronic wound management. She has assisted in the development of a wound assessment tool and a standardised wound care plan and is a member, and past active committee member, of the Wound Management Association of Victoria.

Sharon McNeil RN, BN, Grad Dip (Comm Health)
Sharon has worked for the Royal District Nursing Service for eleven years. Her roles have included: generalist clinical nurse consultant, client services co-ordinator, project officer and, currently, field staff member. She has been involved in writing wound management and clinical procedure manuals. Sharon has a strong interest in improving nursing standards, providing quality nursing care and working with clients and other skilled nurses as part of a home nursing team.

Professional Reviews: