Tài liệu Nursing Documentation in Aged Care: A Guide to Practice pdf

Nursing documentation is often perceived as a tiresome chore. Although this perception of

documentation is understandable, Nursing Documentation in Aged Care: A Guide to Practice is

written from a different perspective. The title of the book is carefully chosen. All of the

contributors to this book firmly believe that nursing documentation in aged care—if performed

with pride and professionalism—is truly a guide to practice.

In striving for the highest standards of professionalism in all that they do, nurses are increasingly

recognising that documentation is a wonderful opportunity to record and reflect upon all that is

good in nursing. In addition to their ethical and professional responsibilities, caring nurses are

aware of the personal satisfaction to be gained from documenting their holistic and reflective

nursing practice.

As another volume in Ausmed’s growing and popular ‘Guide to Practice’

series of textbooks and audiobooks, Nursing Documentation in

Aged Care: A Guide to Practice is an essential text for all aged-care

nurses who wish to enhance their documentation skills and deliver

higher quality care to the elderly.

This book shows how nursing assessments, care plans, and progress notes can allow nurses to

share their knowledge, observations, and skills—and thus make a crucial contribution to their

own professional lives and to the quality of life of those in their care.

This is more than a ‘how-to-do-it’ workbook. With contributions from a range of experts, this

comprehensive evidence-based textbook explores the issues surrounding documentation and

reveals the importance of professional communication within multidisciplinary teams.

Christine Crofton

Christine Crofton is a registered nurse who has been involved in aged care for many

years in a variety of roles—including senior management of aged-care facilities. She is

currently a nurse educator who 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 Witney is registered nurse who 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.

24355_AP_Nursing Documentation Book

C M Y K C M Y K C M Y K

Nursing Documentation

in Aged Care

A Guide to Practice

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Other titles by Ausmed Publications

Nurse Managers: A Guide to Practice

Edited by Andrew Crowther

Aged Care Nursing: A Guide to Practice

Edited by Susan Carmody and Sue Forster

Dementia Nursing: A Guide to Practice

Edited by Rosalie Hudson

Palliative Care Nursing: A Guide to Practice (2nd edn)

Edited by Margaret O’Connor and Sanchia Aranda

Lymphoedema

Edited by Robert Twycross, Karen Jenns, and Jacquelyne Todd

Communicating with Dying People and their Relatives

Jean Lugton

How Drugs Work

Hugh McGavock

Evidence-based Management

Rosemary Stewart

Communication and the Manager’s Job

Annie Phillips

Assertiveness and the Manager’s Job

Annie Phillips

Renal Nursing--A Practical Approach

Bobbee Terrill

Ageing at Home--Practical Approaches to Community Care

Edited by Theresa Cluning

Complementary Therapies in Nursing and Midwifery

Edited by Pauline McCabe

Keeping in Touch--with someone who has Alzheimer’s

Jane Crisp

Geriatric Medicine--a pocket guide for doctors, nurses, other health professionals and students (2nd edn)

Len Gray, Michael Woodward, Ron Scholes, David Fonda & Wendy Busby

Living Dying Caring--life and death in a nursing home

Rosalie Hudson & Jennifer Richmond

Caring for People with Problem Behaviours (2nd edn)

Bernadette Keane & Carolyn Dixon

Practical Approaches to Infection Control in Residential Aged Care (2nd edn)

Kevin Kendall

Nursing the Person with Cancer--a book for all nurses

Edited by Gordon Poulton

Caring for the Person with Faecal Incontinence--a compassionate approach to management

First edn authors: Karen Cavarra, Andrea Prentice & Cynthea Wellings

Second edn author: Janette Williams

Spirituality--the heart of nursing

Edited by Susan Ronaldson

Nursing Documentation--writing what we do

Edited by Jennifer Richmond

Thinking Management--focusing on people

Edited by Jean Anderson

All of these titles are available from the publisher:

Ausmed Publications

277 Mt Alexander Road, Ascot Vale, Melbourne, Victoria 3032, Australia

website: <www.ausmed.com.au>

email: <[email protected]>

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Nursing Documentation

in Aged Care

A Guide to Practice

Edited by Christine Crofton and Gaye Witney

Foreword by Rosalie Hudson

AUSMED PUBLICATIONS

MELBOURNE – SAN FRANCISCO

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Copyright ©Ausmed Publications Pty Ltd 2004

Ausmed Publications Pty Ltd

Melbourne – San Francisco

Melbourne office:

277 Mt Alexander Road

Ascot Vale, Melbourne, Victoria 3032, Australia

ABN 49 824 739 129

Telephone: + 61 3 9375 7311

Fax: + 61 3 9375 7299

email: <[email protected]>

website: <www.ausmed.com.au>

San Francisco office:

Martin P. Hill Consulting

870 Market Street, Suite 720

San Francisco, CA 94102

USA

Tel: 415-362-2331

Fax: 415-362-2333

Mobile: 415-309-2338

email: <[email protected]>

Although the Publisher has taken every care to ensure the accuracy of the professional, clinical, and

technical components of this publication, it accepts no responsibility for any loss or damage suffered

by any person as a result of following the procedures described or acting on information set out in this

publication. The Publisher reminds readers that the information in this publication is no substitute for

individual medical and/or nursing assessment and treatment by professional staff.

Nursing Documentation in Aged Care: A Guide to Practice

ISBN 0-9750445-4-0.

First published by Ausmed Publications Pty Ltd, 2004.

Without limiting the rights under copyright reserved above, no part of this publication may be reproduced,

stored in, or introduced into a retrieval system or transmitted in any form or by any means (electronic,

mechanical, photocopying, recording, or otherwise) without the written permission of Ausmed

Publications. Requests and enquiries concerning reproduction and rights should be addressed to the

Publisher at the above address.

National Library of Australia Cataloguing-in-Publication data

Nursing documentation in aged care : a guide to practice.

Bibliography.

Includes index.

ISBN 0 9750445 4 0.

1. Nursing records - Handbooks, manuals, etc. 2. Geriatric

nursing - Handbooks, manuals, etc. I. Witney, Gaye. II.

Crofton, Christine, 1947- .

610.7365

Produced by Ginross Publishing

Printed in Australia

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Contents

Dedication and Acknowledgments

Foreword

Preface

About the Authors

Chapter 1 Understanding Nursing Documentation 1

Christine Crofton and Gaye Witney

Chapter 2 Clinical Reasoning 19

Bart O’Brien

Chapter 3 Professional Communication 31

Christine Crofton and Gaye Witney

Chapter 4 Nursing Care Plans 45

Shirley Schulz-Robinson

Chapter 5 Progress Notes 63

Joanne Hope and Pamela Bell

Chapter 6 Clinical Pathways 79

Jenni Ham, Ann-Maree Conners, and Angela Crombie

Chapter 7 Documenting Behaviour and Emotion 97

Felicity Humble

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vi

Contents

Chapter 8 Documenting Complementary Therapies 109

Sue Forster

Chapter 9 Documenting Pain Management 123

Michael Cully

Chapter 10 Documenting Restraint 137

Sue Forster

Chapter 11 Incident Reports 151

Adrian Cross

Chapter 12 Documenting Evaluative Criteria 169

Sue Forster

Chapter 13 Documenting Staff Issues 181

Sue Forster

Chapter 14 Effective Design for Documentation 193

John Collins

Chapter 15 A Systems Model for Documentation 209

Christine Crofton and Gaye Witney

Appendix 1 Faecal Incontinence 249

Janette Williams

Appendix 2 Behavioural Management 255

Robyn Daskein

Appendix 3 Diabetes 261

Victoria Stevenson

Appendix 4 Nausea 267

Robyn Millership

Appendix 5 Stomal Care 273

Heather Hill

Appendix 6 Leg Ulcer Management 279

Sue Templeton

Appendix 7 PEG Nutrition 285

Patsy Montgomery

Appendix 8 Wandering 289

Beverly Smith

References 293

Index 299

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Dedication

This book is dedicated to aged-care nurses for their

courage, resilience, and professionalism

and

to the elderly people who share so much of their

lives with the nurses who care for them.

Acknowledgments

To Jim, Jacinta, Robert, Eleanor, and Zoe, who have supported our passion

for aged care, and who have encouraged us in all that we attempt.

To our family and friends, who have been there when needed.

To our industry colleagues for support and inspiration over the years and

to the many skilled nurses who have influenced us during our careers.

To Cynthea and Ausmed Publications for having faith

in us, and for making this book possible.

vii

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Foreword

Rosalie Hudson

Documentation has come alive! In Nursing Documentation in Aged Care:

A Guide to Practice, the drudgery and monotony are taken out of an

important aspect of nursing that has become, for many, a dreaded necessity.

Nurses will be inspired to take a fresh look at the many positive aspects of

documentation and to enjoy the professional rewards of improved practice.

The issues are presented in ways that reinforce current good practice,

encourage reflection on practice, and offer new ideas to guide improved

practice.

The rewards of good documentation are to be found not only in

professional pride, but also in creating more time for resident care.

The book is therefore timely in addressing the frustration expressed by

many aged-care nurses: ‘How can we achieve a good balance between

documentation and resident care?’.

The various models of documentation described throughout this

book will help to identify the unique details of each resident’s care. What

does this record convey about the care of this particular resident? Who is

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x

Foreword

this person in the context of his or her significant relationships? It is this

personal and relational emphasis that makes this book on documentation

come alive.

The practical examples provided will inspire nurses with confidence

to try new approaches. To allow for creativity and flexibility to suit

local circumstances, a variety of options is presented. Each component

of documentation is described and distinguished from others—showing

clearly how to avoid the duplication evident in contemporary practice.

Helpful case studies based on everyday experience make this an enjoyable

book of practical learning.

Throughout this book, communication is the cornerstone of

effective documentation. In communicating with their colleagues,

nurses do more than merely record facts and details; they also evaluate

responses to specific episodes of care and thus learn from one another.

Good communication promotes continuity of care as each person takes up

the story—thus capturing the essence of holistic care. By making explicit

the link between the care and the writing, the documented record is a

profoundly insightful expression of professional holistic care.

Nursing Documentation in Aged Care: A Guide to Practice

challenges nurses to regard quality documentation as a reflection of

quality care. Good documentation is presented as the key to evidence—not

only for legal and regulatory purposes but also for improved professional

practice. Evidence of quality leads to expanded knowledge, and provides

a rich, fertile ground for future research. This book therefore has enduring

qualities. It has the potential to influence the whole of aged-care practice.

Written by people committed to the cause, there is something in every

chapter that will inspire nurses to replace outmoded habits and attitudes

with innovation and clarity of purpose. The purpose of documentation

is clearly articulated throughout the book—to communicate the essence

of resident care in a way that encourages professional pride and paves

the way for best practice to be achieved. Nurses are prompted to write

their documentation in a way that makes nursing visible—thus placing on

record the difference that good nursing makes to the care of residents.

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Nurses will be encouraged by the enduring qualities in this important

and timely book. It not only answers immediate needs but also promotes

documentation in aged care as a model worthy of wider attention by all

nurses.

Rosalie Hudson

Dr Rosalie Hudson is a registered nurse who holds bachelor’s degrees in applied science

and theology, a master’s degree in theology, a graduate diploma in gerontic nursing, and

a PhD. After a long and distinguished career in clinical and academic nursing, including

12 years’ experience as the director of nursing of a 50-bed nursing home, Rosalie is now

a private consultant in aged care and palliative care, and an honorary senior fellow in

the School of Nursing, University of Melbourne. Rosalie has presented and published

numerous papers and articles internationally on the subjects of spirituality, palliative

care, dementia, pastoral care, and ethics at the end of life. Rosalie edited Dementia

Nursing: A Guide to Practice (Ausmed Publications 2003). She has also co-authored

two other Ausmed books, and has contributed chapters to several others. Rosalie enjoys

family life with her husband, adult children, and grandchildren.

xi

Foreword

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Preface

Christine Crofton and Gaye Witney

A guide to practice

Nurses constantly complain that they have insufficient time for proper

documentation. In many ways this is understandable. Nursing is

essentially about caring, and many aged-care facilities today are under￾staffed and under-resourced. In

these circumstances it is hardly

surprising that many nurses

feel that caring comes first and

documentation comes second—that

they have time to care or time to

write, but do not have time for both.

Documentation can be perceived as being primarily an administrative and

legal requirement that takes up valuable time—time that might have been

otherwise spent on resident care.

Although this perception of documentation is understandable,

Nursing Documentation in Aged Care: A Guide to Practice is written from

‘The title of the book is carefully

chosen … nursing documentation

in aged care—if performed with

pride and professionalism—is

truly a “guide to practice”.’

DocumPrelimsFinalProofs.indd 13 26/03/2004 1:06:25 PM

a different perspective. The title of the book is carefully chosen. All of

the contributors to this book firmly believe that nursing documentation in

aged care—if performed with pride and professionalism—is truly a ‘guide

to practice’.

In most jurisdictions, registered nurses are required to adhere

to codes of ethics and codes of professional conduct. They have ‘ … a

responsibility to the individual, society and the profession to provide

safe, competent nursing care which is responsive to individual, group

and community needs’ (ANCI 2000). A nurse’s professional practice with

respect to documentation should reflect such safe, competent nursing

care. Each nurse is responsible for his or her own nursing practice—and

documentation is a part of that responsibility.

In addition to their ethical and professional responsibilities, caring

nurses are aware of the personal satisfaction to be gained from holistic

and reflective nursing practice. In this respect, nurses are increasingly

recognising that documentation

is a wonderful opportunity to

record, share, and reflect upon

all that is good in nursing.

Documentation is more than a

tiresome chore. Comprehensive

and accurate documentation shares astute nursing insights, reflects

the excellence of holistic aged-care nursing, and provides a record of

the professional and personal support that nurses provide every day to

residents and their families.

Nursing Documentation in Aged Care: A Guide to Practice is

therefore written by and for nurses who believe that documentation is

of the utmost importance as a guide to nursing practice—practice that is

ethical, professional, holistic, and reflective.

The purpose of documentation

In documenting aged care, nurses are recording and communicating

information about many important matters. These include (among others):

• care needs—the identification and assessment of the needs of those

in their care;

‘Documentation is of the utmost

importance as a guide to nursing

practice—practice that is ethical, professional, holistic, and reflective.’

xiv

Preface

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