Writing It Down in the Bush

Chapter 11: Writing It Down in the Bush

Overview:

• 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

Description:

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 multistorey hospitals.

Topics:

• 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

Speaker / Author:

Mary Filmer RN, B App Sc (Nursing), Grad Dip Arts (Psychology), MRCNA
Mary 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 writing, using these in her work to promote the wellbeing of clients and other nurses.

Professional Reviews: