Chapter 12: Writing What We Do in the Community
Overview:
- Discusses six main documentation systems used by a group of surveyed nurses
- Provides solutions to present documentation problems
- Focuses on combining client coding systems and documentation
- Describes common legal concerns of community nurses including the fear that their notes might be used in court
Description:
This chapter will examine the documentation Australian community nurses are currently using, the trend towards combining documentation and client coding systems, an instance of community nursing informatics in the US and some legal issues associated with community nursing documentation.
Topics:
- Australian Community Nurse Documentation
- Differences Between Hospital And Community Nursing Documentation
- Commonly Used Methods Of Documentation
- Problems Associated With Present Documentation Methods
- Some Solutions To Present Documentation Problems
- Combined Documentation And Client Coding Systems
- A Community Nursing Informatics Experience In The Us
- Some Community Nursing Documentation Legal Issues
- In Summary
- References
Speaker / Author:
Rozanne Glazebrook
After 30 years’ nursing in many different parts of Australia, Rozanne is currently on contract to the University of Queensland (General Practice Branch) providing field support to Queensland divisions of general practice. She is based in Townsville at the North Queensland Clinical School. Her nursing career commenced with general nurse training in Tasmania. She gained midwifery and child health certificates in Queensland and an intensive/coronary care certificate in Canberra. Rozanne’s other qualifications include Diploma in Teaching (Nursing) from Armidale CAE, Bachelor of Nursing from Deakin University and Master of Public Health and Tropical Medicine from James Cook University.
Rozanne has wide experience of community and child health nursing in Queensland and Victoria. She is also a freelance writer with 90 articles published in journals and magazines.
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