Progress Notes

Chapter 5: Progress Notes

Overview:

• Outlines the purposes and principles of documentation
• Discusses the need of progress notes and the frequency of entries
• Outlines methods of documenting progress notes
• Outlines ethical and legal complications involved in documenting progress notes
• Discusses the need for secure file management and electronic documentation

Description:

Effective communication in aged care is vital to the quality of resident care. Documentation is used to communicate details of the nursing care provided and to inform others of any significant events. There are many legal requirements involved in progress notes and it must always be remembered that a resident’s notes represent a permanent written record of that person’s nursing care and management. This chapter aims to guide nurses on how to effectively and securely document progress notes.

Topics:

• Introduction
• Purposes of documentation
• Principles of effective documentation
• The nature of progress notes
• Responsibility for progress notes
• Frequency and quality of entries
• Common methods of documenting progress notes
  • Problem-oriented documentation
  • Focus charting
  • Charting by exception
  • Narrative progress notes
  • Integrated progress notes
• Ethical and legal implications
  • Confidentiality
  • Subpoenaed notes
  • Avoidance of disciplinary/legal action
• File management
• Electronic documentation
• Conclusion

Speakers /Authors:

Joanne Hope
Joanne graduated as a general nurse from the Royal North Shore Hospital (Sydney, Australia) in 1973. She also holds a diploma in nurse education and a master’s degree in education. Joanne is currently working as a nurse administrator in the aged care sector. Her past positions in aged care have included executive nurse advisor, director of care, deputy director of nursing and education and quality and accreditation coordinator. Before specialising in aged care, Joanne held the position of principal lecturer of nursing at La Trobe University (Victoria, Australia). She has also been a consultant with the World Health Organization.

Joanne is passionate about continuous quality-improvement processes and excellent care outcomes for aged-care residents. She believes that timely, accurate and comprehensive nursing documentation is vital to achieving such outcomes.

Pamela Bell
Pamela Bell is a registered nurse who holds a bachelor of arts degree and a PhD. She was formerly the professor of nursing at Charles Sturt University (South Australia) and is now an honorary senior research fellow in the Faculty of Nursing at the University of Technology (Sydney, Australia). Pam is also a registered psychologist who supervises interns undertaking pre-registration requirements at the College of Psychological Practice, Sydney.

Before becoming an academic nurse, Pam had many years of clinical practice in Victoria and New South Wales. Having grown up in northern Victoria, Pam has an excellent understanding of the problems facing rural health practitioners, and she successfully led the Charles Sturt University component of a joint venture with Monash University in forming the Australian government’s National Rural Health Unit.

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