Nursing Documentation in Aged Care
Documenting Restraint
It is important to correctly document any form of restraint, both physical and chemical. This chapter discusses the use of restraint in an aged care facility and its correct documentation.
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Clinical Reasoning
Clinical reasoning is the process of reaching clinical conclusions through professional judgement, knowledge and experience.This chapter instructs nurses on how to understand Clinical Reasoning, its politics and its conflicts with documentation...
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Documenting Pain Management
This chapter aims to convey correct pain management documentation methods and the difficulties in communication that arise in aged-care...
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Nursing Care Plans
This chapter discusses the use of nursing-care plans (NCPs) in residential aged-care facilities. Nurses and their professional organisations need to think strategically about nursing care and how it is planned and implemented...
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Documenting Evaluative Criteria
Evaluative criteria are measurement parameters that are based upon an accepted rule, standard, or principle. This chapter guides nurses on how to accurately use the parameters of evaluation, and correctly document it...
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Diabetes (APP3) & Nausea (APP4)
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Prelims - Nursing Documentation in Aged Care
Prelims: Dedication, Acknowledgments,Foreword, Preface, Contents and About the Authors
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Clinical Pathways
The aim of a clinical pathway is to achieve quality outcomes within a specified time frame, using the resources that best meet the patients’ needs...
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Effective Design for Documentation
This chapter offers practical advice on the design of effective forms for nursing documentation. The suggestions in this chapter will help nurses to design forms that best suit their purposes...
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PEG Nutrition (APP7) & Wandering (APP8)
Nursing Documentation in Aged Care: Appendix 7 PEG Nutrition; Appendix 8: Wandering
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Professional Communication
This chapter aims to instruct nurses on how to effectively communicate verbally and through documentation including the codes of professional practice...
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Documenting Complementary Therapies
This chapter guides nurses in the documentation of complementary therapies in an aged care facility. This includes the planning stage where policies, procedures and protocols must be considered...
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Understanding Nursing Documentation
It is essential that all aged care facilities have a clear vision of their objectives and requirements with respect to nursing documentation. This chapter instructs nurses on the basics of nursing documentation, including the legal issues involved...
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Incident Reports
The reporting of incidents is a vitally important aspect of nursing documentation. This chapter guides nurses on how to accurately report an incidence and to ensure a higher level of safety for both staff and residents in an aged care facility...
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Faecal Incontinence (App1) & Behavioural Management (APP2)
Nursing Documentation in Aged Care: Appendix 1: Faecal Incontinence;
Appendix 2: Behavioural Management
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Endmatter - Nursing Documentation in Aged Care
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Progress Notes
Documentation is used to communicate details of the nursing care provided and to inform others of any significant events. This chapter aims to guide nurses on how to effectively and securely document progress notes...
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Documenting Staff Issues
Human resources represent an organisation’s most valuable resource. This chapter explains the explicit procedural documents that must accompany each human-resources management policy...
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Stomal Care (APP5) & Leg Ulcer Management (APP6)
Nursing Documentation in Aged Care: Appendix 5: Stomal Care;
Appendix 6: Leg Ulcer Management
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Documenting Behaviour and Emotion
All nurses experience and observe the behaviour and emotion of those in their care throughout their work day. This chapter guides nurses on how to accurately assess and document emotion and behaviour...
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