A Systems Model for Documentation

Chapter title: A System Model for Documentation - Chapter 15

Overview:

• Outlines the preparatory work needed before establishing a system of documentation in a facility
• Highlights the need for an educational program to establish positive attitudes to documentation
• Outlines the essential tools needed for effective documentation
• Highlights the importance of sharing documentation experiences with colleagues in the nursing industry

Description:

This final chapter takes a broader view of the subject in presenting a systems model for professional nursing documentation in aged care. In presenting a systematic overview of documentation, the chapter draws together many of the topics considered in earlier chapters and presents them in one coherent model. The model presented here puts many of the topics of earlier chapters into an overall context.

Topics:

• Introduction
• Preparatory work
  • Clinical governance and documentation
  • Evidence-based practice
  • Philosophy
  • Regulatory compliance
  • Quality systems
  • Policies and procedures
  • Research
  • Summary of preparatory work
• Education
• Documentation essentials
  • Assessment and nursing diagnosis using nursing-assessment tools
  • Nursing-care plans
  • Progress notes
  • Assessment
  • Auditing
  • Benchmarking
• Publishing
  • Journal articles
  • Conference presentation
• Conclusion

Speakers /Authors:

Christine Crofton
Christine is a registered nurse who holds a bachelor’s degree in education and training, diplomas in frontline management and business (community services and health) and certificates in gerontology, training and development, assessment and workplace training. Christine has been involved in aged care for many years as a registered nurse in various roles—including senior management of aged-care facilities. She is currently a nurse educator and is completing her master’s degree in education and training.

Christine 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 is a registered nurse who holds a bachelor’s degree in education and diplomas in primary education, training and development, frontline management, and business (community services and health), and certificates in gerontic nursing, management, industrial education and training, personal skills development, training, and workplace assessment. She is currently undertaking studies towards her master’s degree in education. Gaye 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.

Professional Reviews:

The information provided has been very helpful to remind me of the basic need to the focal point of the documentation ie how, why and when? This is vital in obtaining positive outcome of relevance to issues.

Hello Cristine and Gaye,  I am a Registered Nurse working in an Aged Care and I alwaays wanted to know more about Documentation, and how we can improve. Well, thanks very much, this is been very helpful. I have a better understanding of Documentation.  Vanessa.