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Nursing Documentation in Aged Care

Clinical Reasoning

Type: eChapter
Book Title:	Nursing Documentation in Aged Care
Chapter:	2
This education is:	eligible for CPD

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Chapter 2: Clinical Reasoning

Overview:

Describes the nature of clinical reasoning with reference to the decision theory, the information-processing theory; and the skills-acquisition theory
Outlines the politics involved with clinical reasoning
Discusses the conflicts that can arise between clinical reasoning and documentation
Outlines effective documentation

Description:

Clinical reasoning is the process of reaching clinical conclusions through professional judgement, knowledge and experience. It also involves an understanding of the politics of clinical practice. Nurses in aged care need to understand the regulatory, political and social customs that dictate the care that is provided, when it is provided and who provides it. This chapter instructs nurses on how to understand Clinical Reasoning, its politics and its conflicts with documentation.

Topics:

Introduction
The nature of clinical reasoning
- Three theories
- Nurses’ understanding of those in their care
Politics of clinical reasoning and documentation
Conflicts between clinical reasoning and documentation
- Theoretical plans and clinical experience
- Differing expectations
Effective documentation
Conclusion

Speaker/Author:

Bart O’Brien
Bart is registered nurse who holds a bachelor’s degree and postgraduate qualifications in nursing. Bart has worked in a variety of position in residential aged care since 1986 including educator, clinical nurse consultant, assistant director of nursing, consultant, continence advisor and quality coordinator. His PhD thesis was on the subject of nursing praxis—what nursing does to improve care and outcomes for residents. As a result of this and other research, Bart has contributed to the development of a practice-based model for aged-care nursing. Bart has edited, written and co-authored a number of books and monographs, book chapters, refereed journal articles and research reports and is frequently invited to contribute to the professional development of aged-care nursing through participation in seminars, lectures, consultations and research projects. He is a member of the Royal College of Nursing, Australia, and is currently the quality coordinator at the James Brown Memorial Trust, Belair (South Australia).

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