Chapter 1: Understanding Nursing Documentation
Overview:
- Discusses the importance and purposes of nursing documentation
- Outlines the legal issues and ethics involved in nursing documentation
- Describes nursing practise protocol in regards to documentation
- Discusses the key management issues of documentation
Description:
Nursing documentation is vitally important, and it is essential that all aged care facilities have a clear vision of their objectives and requirements with respect to this aspect of care. It is essential that nurses follow the documentation requirements of the organisation in which they work. This chapter instructs nurses on the basics of nursing documentation, including the legal issues involved.
Topics:
- Introduction
- Key terms
- Importance of documentation
- Purposes of documentation
- Leadership
- Legal issues
- Ethics
- Values
- Nursing practice
- Codes of conduct
- Standards of practice
- Holistic nursing practice
- Reflective nursing practice
- Praxis
- Management issues
- Language, jargon, and forms of expression
- Documentation not being performed
- Qualifications of nursing staff, levels of experience, and staff skills mix
- Attitudes of nursing staff to documentation and time management skills
- Government regulation
- Conclusion
Speaker/Author:
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 registered nurse who holds a bachelor’s degree in education, 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.
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