Nursing Documentation: Writing What We Do
Prelims - Nursing Documentation writing what we do
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Accounting For Care: Documenting Residential Aged Care Nursing
This chapter explores the problem of documentation in nursing homes. It outlines the forces that influence written records of caregiving in nursing homes and considers specific fatcors that inhibit progress towards a professional standard of documentation
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Social Assessment Documentation: Genograms and Ecomaps
This chapter explores the use of genograms and ecological maps (commonly called ecomaps) in acquiring a better understanding of patients, allowing nurses to provide them with a better standard of care...
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Documented Life and Death In a Nursing Home
This chapter provides a hypothetical account of the last year in an elderly man’s life. The chapter will provide an overview of his care in order to emphasise the fact that good documentation always underpins the preferred client outcome...
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Charting by Exception in Aged Care
Charting by exception (CBE) is an exciting development in nursing documentation. This chapter focuses on charting by exception and includes guidelines, support processes as well as issues to consider when implementing this new practice...
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Documenting the Cultural Dimension of Practice
This chapter explores the ways three New Zealand nurses have found to document the cultural dimension in practice. From their work in diverse communities, they explain the emphasis they place on culture when assessing and documenting aspects of health...
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Legal Issues in Documentation
At no point can you afford to be careless in your attitude towards documenting nursing care. In this chapter, learn about the importance of contemporaneous record keeping, about the legal complications of poor documentation and more...
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Clinical Nurse Consultation: Documenting Diabetes Education, The
Documentation by DEs must meet the requirements of good documentation specified by nursing bodies and the law. This chapter explains these requirements and addresses specific issues relevant to the practice of diabetes education...
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Looking to the Future: Critical Pathways
This chapter educates nurses on critical pathways; multidisciplinary patient-care tools used in case management models to co-ordinate and facilitate the efficient and effective management of various patient groups.
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Charting the Waters of Client’s Emotions
This chapter emphasises the importance of including clients’ subjective or emotional responses in nursing documentation. Documenting their emotional status helps inform other team members, so the most appropriate care can be planned and implemented...
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Documenting the Intangible
This chapter discusses how to assess the spiritual needs of patients in order to become better equipped with providing care...
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Writing It Down in the Bush
The demands of documentation may seem never-ending and almost impossible to manage at a small rural centre. This chapter provides useful suggestions for ensuring documentation standards are as good as those of any city’s multistorey hospitals...
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Writing What We Do in the Community
This chapter will examine the documentation Australian community nurses are currently using, the trend towards combining documentation and client coding systems and some legal issues associated with community nursing documentation....
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Health Records in the Home
This chapter explains the advantages and potential conflicts of using home health records. It shows that the aim of community nursing is to establish a partnership between nurse and client which empowers clients to participate fully in their own care...
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American Experience, The
This chapter will provide a brief history of the transition to managed health care in the United States and outline the implications for Australian nurses, especially in relation to demands for increased documentation practices...
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Political Imperative: Nurses' Work Visible by Documentation
What nurses document in their work conveys to others what nurses do. It is only by documenting what was done and how this was received that the quality of nursing care will improve and what nurses do will be recognised as worthwhile...
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Documenting Dementia Using Assessment Tools
This chapter explores the use of a variety of different geriatric assessment tools and discusses their purposes. It focuses particularly on assessment tools designed for emotional, mental and behavioural assessment...
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Documentation Review: Developing a New Record
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...
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Designing a Form for Your Needs
This chapter offers some tips to help you design a better form; one that will do exactly what you want. Follow simple steps in order ensure that your forms are well-designed and easy to fill out...
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End Matter - Nursing Documentation writing what we do
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