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

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

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

Nursing Documentation

in Aged Care

A Guide to Practice

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

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:

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

Copyright ©Ausmed Publications Pty Ltd 2004

Ausmed Publications Pty Ltd

Melbourne – San Francisco

San Francisco office:

Martin P Hill Consulting

870 Market Street, Suite 720

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.

Produced by Ginross Publishing

Printed in Australia

Dedication and Acknowledgments

Foreword

Preface

About the Authors

Christine Crofton and Gaye Witney

Bart O’Brien

Christine Crofton and Gaye Witney

Shirley Schulz-Robinson

Joanne Hope and Pamela Bell

Jenni Ham, Ann-Maree Conners, and Angela Crombie

Felicity Humble

Christine Crofton and Gaye Witney

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

DocumPrelimsFinalProofs.indd 8 26/03/2004 1:06:24 PM

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

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

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

DocumPrelimsFinalProofs.indd 12 26/03/2004 1:06:24 PM

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”.’

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

• care plans and progress notes—the documentation of

nursing-care plans to address these needs, and the subsequent progress of residents;

• communication and teamwork—the communication of this

information among members of the healthcare team, thus ensuring teamwork, shared responsibility, and continuity of care;

• education and research—the professional sharing of insights,

knowledge, and trends in aged-care nursing;

• legal requirements—a legal record to protect residents, nurses, and

the organisation in which they live and work; and

• auditing and funding—a validation of the standards of nursing care

and the establishment of documented links between the level of nursing care and the resources required to support it

This book therefore shows how professional documentation allows 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

The structure of this book

The book begins with three chapters that provide comprehensive

overviews of the broad subject of nursing documentation in aged care The

first chapter, ‘Understanding Nursing Documentation’, sets the scene with

a general discussion of the major issues The second chapter, ‘Clinical

Reasoning’, explores how nurses make clinical decisions and canvasses

the interaction (and possible conflict) between real nursing experience

and administrative documentary requirements This is followed by a

chapter on ‘Professional Communication’—stressing the significance

of documentation as an exercise in effective communication between

professional colleagues in a multidisciplinary team

Having canvassed these broad introductory issues, the book then moves on to discuss three important forms of nursing documentation—

‘Nursing Care Plans’, ‘Progress Notes’, and ‘Clinical Pathways’

This is followed by chapters on some selected clinical issues that can provide documentation problems—‘Documenting Behaviour and

xv Preface

Emotion’, ‘Documenting Complementary Therapies’, ‘Documenting Pain

Management’ and ‘Documenting Restraint’

The book then moves onto a consideration of the documentation

of wider managerial and administrative issues—‘Incident Reports’,

‘Evaluative Criteria’, and ‘Documenting Staff Issues’

The second-last chapter of the book provides some helpful advice

on ‘Effective Design for Documentation’—with hints on how to design

documentation forms that are functional and effective

The final chapter in the main body of the book draws everything together in a comprehensive ‘Systems Model for Documentation’ The

model presented here puts many of the topics of earlier chapters into

an overall context In doing so, it provides guidance to clinical nurses

and nurse managers in how to go about establishing a comprehensive

documentation system that promotes positive attitudes and outcomes with

respect to this vital aspect of aged-care nursing

Following the main body of the book, several case studies are discussed in the appendices These short case studies present common

clinical problems and provide examples of the types of documentation that

are appropriate in each case

In keeping with the evidence-based nature of the text, the book concludes with a list of references and a comprehensive, cross-referenced

index

A wide-ranging, evidence-based textbook

This is therefore more than a ‘how-to-do-it’ workbook on nursing

documentation With contributions from a range of experts, this

wide-ranging, evidence-based textbook explores the issues surrounding documentation, reveals the importance

of effective communication within multidisciplinary teams, and guides nurses in enhancing their professional practice

‘More than a it’ workbook on nursing documentation … this wide-

‘how-to-do-ranging, evidence-based textbook explores the issues

surrounding documentation.’

xvi

Preface

The authors of this book trust that it can help aged-care nurses to see documentation as more than a necessary burden Rather, documentation

can be an exciting and valuable aspect of their shared professional lives

The authors believe that this book will assist aged-care nurses to

recognise that they have control over the philosophy and application of

documentation in an increasingly difficult work environment If performed

with pride and professionalism, nursing documentation in aged care can

truly be a ‘guide to practice’

xvii Preface

DocumPrelimsFinalProofs.indd 18 26/03/2004 1:06:25 PM

About the Authors

Adrian Cross

Chapter 11

Adrian Cross holds a diploma in production engineering, a degree in arts, and a graduate

diploma in ergonomics Adrian worked in industry for 25 years, dealing with quality

assurance and occupational health and safety He then worked in the public service

for 15 years specialising in facilities’ management—including the management of

hospitals and aged-care facilities Adrian is now a lecturer in aged-services management

and occupational health and safety at Victoria University and Kangan Batman TAFE

(Melbourne, Australia).

Pamela Bell

Chapter 5

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

John Collins

Chapter 14

John Collins holds a diploma in continuing education, a bachelor’s degree in arts,

and a master’s degree in education He has worked as a senior bureaucrat in a

number of educational systems This employment has involved him in the design

and implementation of a range of records and documents John is well aware of the

importance of well-designed and user-friendly forms for documentation.

Ann-Maree Conners

Chapter 6

Ann-Maree Conners is a registered nurse and midwife who holds bachelor’s and

master’s degrees in health science For the past five years, she has been the director of

the Collaborative Health Education & Research Centre (CHERC) of Bendigo Health

Care Group (Victoria, Australia), and has recently been appointed to the role of acting

group director of nursing at the Bendigo Health Care Group Ann-Maree has extensive

experience in the development and coordination of education programs for registered

nurses and has been involved in health research for a number of years Her research

interests have included (among others): video-conferencing of educational models; a

regional telerehabilitation project; post-acute-care programs in regional hospitals;

care-planning in rural areas utilising critical-pathway methodology; and community nursing

clinical pathways for providers of care to veterans.

Christine Crofton

Subject specialist editor, Chapters 1, 3, 15

Christine Crofton 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.

Angela Crombie

Chapter 6

Angela Crombie is a registered nurse who holds a bachelor’s degree in nursing and

master’s degree in health science Angela also holds additional qualifications in

psychiatric nursing and workplace assessment and training She is employed as a

xx

About the Authors

research officer and nurse educator with the Collaborative Health Education & Research

Centre (CHERC) of Bendigo Health Care Group (Victoria, Australia), specialising in

research and education on aged-care issues Angela has been involved in a number of

research projects, many of which have included the design and development of care

pathways in a variety of settings Some of these projects have included: a regional

dementia management strategy; health assessments under Medicare schedule items;

asthma management in rural Victoria; health surveillance in the elderly using a

health-surveillance screening instrument; and home and community care best-practice

projects.

Michael Cully

Chapter 9

Michael Cully is a registered nurse with a degree in education, a graduate diploma in

education and training, and a master’s degree in nursing studies He is a nurse educator

at Ipswich Hospital (Queensland, Australia) with interests in mental-health nursing,

care of older persons, and aggression minimisation Michael has a particular interest

in the mechanics of clinical decision-making under conditions of uncertainty In his

spare time, he listens to classical music, enjoys the company of his family, walks in the

national parks of south-eastern Queensland and north-eastern New South Wales—and

wonders whether the Carlton Football Club will ever win another premiership!

Robyn Daskein

Appendix 2

Robyn Daskein is a registered nurse who holds a diploma in nurse education, a bachelor’s

degree in applied science (nursing) and a master’s degree in health administration She is

currently undertaking doctoral studies Robyn is the national quality assurance manager

for the Regis Group In this role, she maintains the company’s continuous-improvement

systems across 16 aged-care facilities in Queensland and Victoria (Australia) Robyn

has been working in aged care and has been an aged-care registered nurse adviser since

1987 As director of her own company, Health Care Essentials, Robyn has specialised

in providing education, continuous quality improvement, and management services

to the aged and community care industry Robyn’s PhD studies are directed towards

quality outcomes in documenting challenging behaviour in residential aged care

Sue Forster

Chapters 8, 10, 12, 13

Sue Forster completed her general nurse training in the Queen Alexandra Royal Naval

Nursing Service in the UK and abroad She has extensive clinical, educational, and

managerial experience at senior levels gained from a long nursing career in Europe,

Australia, and Africa For the past ten years Sue has managed her own educational

consultancy business Her special interests include gerontic care, continuous quality

xxi About the Authors

improvement, and human-resource management Sue is dedicated to the education and

empowerment of her nursing colleagues through the provision of sound evidence-based

practice within an holistic framework of quality care.

Jenni Ham

Chapter 6

Jenni Ham is a registered nurse and midwife who holds a graduate diploma and a

master’s degree in health science Since 1994, she has worked as a project manager and

acting operations manager at the Collaborative Health Education & Research Centre

(CHERC) of the Bendigo Health Care Group (Victoria, Australia) Jenni has extensive

experience in the design and implementation of clinical pathways Her research projects

have included the design, implementation, and evaluation of clinical pathways in acute

and rehabilitation settings, and the design and implementation of clinical pathways in

smaller rural hospitals Jenni and her colleagues at CHERC have demonstrated that

clinical pathways can be implemented successfully for patients with complex needs

Jenni’s work has achieved national recognition, as demonstrated by frequent invitations

for her to present at workshops and conferences.

Heather Hill

Appendix 5

Heather Hill is a fellow of both the New South Wales College of Nursing and the Royal

College of Nursing, Australia She is also a life member of the Australian Association

of Stomal Therapy nurses and the World Council of Enterostomal Therapy Heather

has been involved in clinical practice and education in stomal nursing since 1981 She

has lectured extensively and has written papers for nurses, allied health personnel,

doctors, and laypeople Heather has presented at numerous international conferences

and seminars and was the onsite clinical co-educator for the inaugural stomal-therapy

course conducted by the Singapore Ministry of Health and Singapore Cancer Society

Joanne Hope

Chapter 5

Joanne Hope 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 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

xxii

About the Authors

She believes that timely, accurate, and comprehensive nursing documentation is vital

to achieving such outcomes.

Felicity Humble

Chapter 7

Felicity Humble is a registered nurse and registered psychiatric nurse who holds

bachelor’s and master’s degrees in nursing, and a diploma in applied science (advanced

psychiatric nursing) Despite being ‘in a nervous and unprepared state’ when she was

sent to the psychiatric ward for her last rotation as a student general nurse in 1975,

Felicity fell in love with this area of nursing and has remained passionately interested in

psychiatric nursing ever since Throughout this time she has been enriched by an array

of experiences with the elderly, and has worked with aged patients in acute admission,

rehabilitation, and secure settings She has also been part of a community mental-health

team for the aged in which she was involved in the assessment and management of

aged people in their own homes or in other accommodation settings in the community

Over the past 12 years Felicity has worked as a clinical educator with undergraduate

student nurses—helping them make sense of their psychiatric nursing experience and

endeavouring to raise their interest in a career in mental health She has also had several

years’ experience working with postgraduate psychiatric nurses Felicity is currently a

psychiatric nurse educator working with nursing staff at Barwon Health Community

and Mental Health (Geelong, Australia).

Robyn Millership

Appendix 4

Robyn Millership is a registered nurse and registered midwife who holds diplomas in

nursing education, intensive care, and ward management She also holds a certificate

in palliative care Robyn has worked in palliative care as a nurse consultant for more

than 15 years Her background is diverse including clinical practice, intensive care,

administration, and education Robyn is passionately committed to providing excellence

in symptom control for patients with terminal illnesses She believes that most people

can achieve what seem to be impossible goals if they are provided with optimal

symptom control, knowledge, encouragement, and support Robyn was a recipient of a

Victorian Nurses Care Award in 1994 She is currently a nurse consultant in palliative

care at the Peter MacCallum Cancer Institute, St Vincent’s Hospital and Caritas Christi

(both Melbourne, Australia).

Patsy Montgomery

Appendix 7

Patsy Montgomery is a registered nurse, registered midwife, and stomal therapist who

holds a bachelor’s degree in educational studies She is co-founder and consultant

xxiii About the Authors

for the Gastrostomy Information Support Service, president of the Peninsula Ostomy

Association (Melbourne, Australia), and the coordinator and clinical nurse consultant

for the Abbott Nutrition Service, Victoria (Australia) Patsy’s role is to provide a support

service for tube-fed people, their families, and their carers when patients are discharged

from hospital into the community This includes information and help for managing

enteral tubes and equipment, advice about methods of feeding and nursing care, and

information regarding supplies of formula, equipment, and pumps Patsy also provides

education and practical ‘hands-on training’ for gastrostomy-fed people and carers

She also provides in-service training, workshops, videos, and literature for healthcare

professionals.

Bart O’Brien

Chapter 2

Bart O’Brien 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).

Shirley Schulz-Robinson

Chapter 4

Shirley Schulz-Robinson has worked for 30 years as a clinician and manager in

various practice settings—including psychiatric nursing, developmental disability

nursing, medical and surgical nursing, women’s health, and community health For

19 years she worked in nurse education, including terms as the clinical director and

assistant dean in the Faculty of Nursing at Newcastle University (Australia) Shirley’s

research interests include community-health nursing, health policy, and collaborative

health-promotion strategies with patients and communities Her current research has

demonstrated that much of the work undertaken by nurses is hidden, and that it is

commonly attributed to the efforts of other professions Shirley has been chairperson

of the Hunter Chapter of the Royal College of Nursing, Australia, president of the New

South Wales Community Health Association, a member of the Public Health Research

and Development Committee of the National Health and Medical Research Council

xxiv

About the Authors

(Australia), and a member of the New South Wales Nurses Tribunal Shirley retired

from Newcastle University in 2003 to devote more time to writing and consulting.

Beverly Smith

Appendix 8

Beverly Smith holds a bachelor of nursing, a certificate of rehabilitation and extended

care, and postgraduate diplomas in gerontological nursing and aged-care services

management Beverly has had varied experience as a clinical nurse specialist and

manager in Melbourne (Australia)—at first in rehabilitation, and later in aged-care

services As a result of these experiences, and her work as an external aged-care

standards agency assessor, she has developed a particular interest in documentation

Beverly believes that documentation should be succinct, creative, and streamlined to

focus on maximising the life opportunities of residents.

Victoria Stevenson

Appendix 3

Victoria Stevenson is a registered nurse and registered midwife who holds a graduate

diploma in health education She is completing her master’s degree in nursing Victoria

is a fellow of the Royal College of Nursing, Australia, and is a credentialled diabetes

educator with the Australian Diabetes Educators Association (ADEA) who has

established a diabetes education service at Maroondah Hospital and further diabetes

services at the Alfred Hospital (both Melbourne, Australia) She began part-time private

practice many years ago Victoria speaks frequently at seminars and conferences and

has co-authored and produced a video ‘Diabetes—Understanding It’ She is a past

vice-president and national conference convenor of the ADEA and has represented members

on a number of committees Victoria is currently the diabetes clinical nurse coordinator

at the Alfred Hospital Her role includes promotion of nursing practice in this speciality

area, collaboration with health providers to provide education for people with diabetes,

staff education, and participation in professional community services.

Sue Templeton

Appendix 6

Sue Templeton is a registered nurse who holds a bachelor’s degree in nursing, a

certificate in hyperbaric nursing, and a certificate in orthopaedic nursing She has more

than 15 years’ experience in the management of acute and chronic wounds and has

contributed to the development of wound-assessment tools and clinical pathways for

the management of venous leg ulcers Sue frequently conducts wound-management

education for nurses in a variety of settings and has published and presented at local

and national forums She is a clinical nurse consultant and advanced wound specialist

with the Royal District Nursing Service of South Australia, a clinical tutor with the

University of Adelaide, and a member of the South Australian Wound Management

xxv About the Authors

Association, the South Australian Vascular Nurses Society, and the Australian Council

of Community Nursing Services.

Janette Williams

Appendix 1

Janette Williams is a registered nurse who holds a master’s degree in nursing bioethics

Janette has worked as a continence consultant for more than 12 years She planned and

conducted the original continence training course in New South Wales (Australia) and

has been involved in the Continence Foundation of Australia at national and international

levels Janette is immediate past chairperson of the Australian Nurses for Continence

She is the author of the Ausmed publication, Management of Faecal Incontinence.

Gaye Witney

Subject specialist editor, Chapters 1, 3, 15

Gaye Witney 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.

xxvi

About the Authors

Chapter 1

Understanding Nursing Documentation

Christine Crofton and Gaye Witney

Introduction

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 Many time-consuming

and costly ‘documentation issues’

can be avoided if a clear vision

and accompanying guidelines are

provided for all nursing staff To

avoid incomplete, inconsistent,

ambiguous, and reactive documentation, it is essential that nurses

understand the documentation requirements of the organisation in which

they work Poor documentation can put residents at risk and can jeopardise

funding to the organisation

An organisation must therefore be positive, proactive, and definite about what it requires of nurses, and must ensure that processes are in

place to guide and support them to fulfil these requirements Time and

‘Poor documentation can put residents at risk and can jeopardise funding to the organisation.’

commitment will be required if the organisation is to ensure that staff

members are informed and educated with respect to its expectations

Key terms

Before exploring the subject in greater detail, it is helpful to establish an

understanding of the terminology used in this important subject The Box

below contains a glossary of some key terms

Glossary of key terms

Documentation

Documentation can be defi ned as a written record of proceedings It is a

collection of documents that provides an account of the care delivered by

the multidisciplinary healthcare team.

Leadership

Leadership is a commitment to assisting others to feel, think, or behave

in a certain way A leader is someone who has a vision, takes action, and

demonstrates a commitment to the documentation process.

Ethics

Ethics are principles that act as a guide to decision-making for nurses

involved in the documentation process.

Values

Values are the personal rules by which nurses live They are the ‘silent

factors’ that infl uence and shape a nurse’s practice Values develop from

the infl uence of signifi cant people and events through life and can affect all

aspects of a nurse’s practice, including how he or she regards the issue of

documentation.

Standards of practice

Standards of practice are expectations of professional nursing conduct

Registered nurses accept the professional responsibility and trust inherent

in their role, and are required to adhere to professional codes of conduct.

2

Nursing Documentation

Importance of documentation

Nursing documentation is central to quality nursing care, and is essential to

the appropriate and accurate management of people in care Documentation

is essentially about communication, and must therefore make sense and

have meaning if it is to be a communication tool for all involved

It is essential to have a documentation system in place All those

involved in the care of residents must be aware of their responsibilities,

duty of care, and the requirements of the organisation In instituting

such a system, it should be noted

that documentation has moved from

a ‘medical focus’ (whereby nurses

documented their care to ensure that

doctors’ orders were followed) to a ‘nursing focus’ (in which nurses

initiate nursing care and ensure that the nursing process is followed) The

two models are complementary, and accurate documentation ensures that

appropriate and consistent nursing care is planned and implemented in

accordance with medical diagnoses

Purposes of documentation

The purposes of documentation are:

• to act as a communication tool by enabling clear, concise, and

relevant information to be exchanged among those involved in the care of residents;

• to ensure continuity of care with respect to residents’ nursing care

• to act as an educational tool; and

• to meet funding requirements by providing all required statutory

information

‘Documentation is essentially about communication.’

3 Understanding Nursing Documentation

Leadership is required within an organisation when setting the standards

for documentation The minimum requirements for documentation are the

imposed documentation processes linked with a funding model, but many

organisations are showing leadership by choosing to go beyond these

minimal requirements

A documentation process that is restricted to the requirements of a funding model can be perceived by nursing staff as a burden to be borne, and

negative attitudes can easily develop If the leadership vision goes beyond

mere funding requirements, a positive environment can be created in which standards of excellence are set and in which the leader can become a true agent and facilitator of change In these circumstances, nurses become involved,

are inspired, and develop confidence in themselves and the importance of

• seek input from others (and value the information);

• create a learning culture;

• be positive about managing the documentation process;

4

Nursing Documentation

‘If the leadership vision goes beyond

mere funding requirements, a positive environment can be created.’

5 Understanding Nursing Documentation

• push the boundaries; and

• be aware of their own strengths while seeking support and guidance

as appropriate

Legal issues

Various statutory requirements dictate the professional practice of

registered nurses in all respects—including nursing documentation As

professionals, nurses are required to uphold a duty of care, and all nurses

must be aware of the implications of this with respect to documentation

Precise responsibilities and constraints vary from jurisdiction to

jurisdiction, but the Box below lists some of the important principles to

be observed

Legal constraints on documentation

Precise legal requirements with respect to documentation vary from

jurisdiction to jurisdiction, but some of the legal principles that apply

include:

• Confi dentiality—once information is collected, it must be protected.

• Objectivity—facts should be recorded; nurses should not make

assumptions or give personal opinions; documentation should be specifi c, factual, accurate, concise, and evidence-based; residents can be quoted when appropriate.

• Date, time, and designation—whenever a record is made, the date,

time, and nursing staff designation must be recorded to ensure that the writer is identifi ed and that an accurate sequence of events is recorded

• Permanency—notations must be made in permanent blue or black ink;

records can become legal documents in a court of law.

• Timing—best practice requires that the notations be made in the

record as things happen (rather than being recorded some time after the event).

• Legibility—what is written must be legible to all members of the

multidisciplinary healthcare team; mistakes can be made if team members are unable to read entries in the notes.

(continued)

The ethics of documentation can be challenging for nurses The

fundamental ethics of nursing dictate that nurses promote and restore

health, prevent illness, and alleviate suffering—and these requirements

must be reflected in everything that is written A failure to record incidents

can lead to a communication breakdown for the whole team and can affect

resident outcomes For example, it is inappropriate to fail to document an

incident because ‘that is how the resident always is’

6

Nursing Documentation

(continued)

• Abbreviations—a consistent set of abbreviations should be used to avoid

confusion; many facilities now have a recognised list of abbreviations to

be used by all team members.

• Access—it is essential that all appropriate legal constraints be followed

with respect to access to records, and nurses must be aware of these constraints if requests are made for access; in most cases, there is unlimited access to a resident’s records by members of the multidisciplinary healthcare team caring for that person.

• Storage—records must be stored in a secure place, with access being

limited only to authorised people.

• Destruction—a record must be kept for a specifi c time (as per local

regulations) after the last admission or death of a resident; the record can then be destroyed by shredding.

• Blank spaces—no blank spaces are to be left after the documentation

is completed; if the line has not been fi lled, it might be appropriate to draw a line through the space to the end of the line.

• Corrections—if an error is made, a line should be drawn through the

error, the word ‘error’ should be entered, and the notation should be initialled and dated; errors should not be erased, and ‘whiteout’ should not be used.

• Personal responsibility—nurses should never document for someone

else, nor sign another person’s name; nursing documentation is a legal record.

Nurses and the organisation need to be open, honest, and willing to discuss ethical documentation issues as they arise Conflict can occur, but

with professional understanding and healthy debate, appropriate decisions

will be reached Consensus should always be sought on contentious ethical

issues It is inevitable that some people will be somewhat dissatisfied with

the decisions reached, but this is part of professional life and personal

growth Once a decision has been made, all nursing staff must be informed

of the outcome and the documentation requirements that will result from

that decision

Conflict between various team members regarding documentation can have adverse effects on residents and can cause ethical issues for

nurses A mismatch between the values and beliefs of an individual nurse

regarding documentation and those of the rest of the multidisciplinary

healthcare team (or the organisation as a whole) is referred to as ‘cognitive

dissonance’ If a nurse continues to work in this environment, his or her

satisfaction with the situation will decrease and can cause increasing

discontent and poor morale in the workplace This must be acknowledged

and addressed If not, it will affect the quality of care, choices, and dignity

of both residents and staff

To avoid these sorts of problems, a set of ethical guidelines with respect to documentation should be observed by the organisation

A suggested set of such guidelines is presented in the Box on page 8

Values

Values make up the inner world of personal hopes, ideals, dreams, and

images by which nurses judge the outer world of everyday life and human

behaviour Values are thus the filter through which nurses view the world

and by which they judge what is important to them and society As Hall

(1995, p 21) observed: ‘Values are

the ideas that give significance to our

lives, that are reflected through the

priorities that we choose, and that we

act on consciously and repeatedly’

Values thus affect everything in professional life, including nurses’

responses to documentation requirements The ethical demands on nurses

7 Understanding Nursing Documentation

‘Values are the filter through which nurses view the world and judge what is important to them.’

Nursing Documentation

with respect to documentation are demanding (see above), and if nurses

fail to recognise or respond to conflicts between their own values and the

ethical requirements put upon them, their documentation practice will

suffer

Ethical guidelines for documentation

To ensure the highest standards of professional practice in documenting

nursing care, the following ethical guidelines are suggested.

• Nurses should respect the lives, dignity, and rights of all residents, irrespective of ethnic origin, age, gender, politics, or social status.

• Nurses should acknowledge the values, customs, and spiritual beliefs of all residents.

• Nurses should maintain the dignity of residents at all times in terms of what they write about residents, their familes, and signifi cant others.

• Nurses should take personal and professional responsibility for what they write and must ensure that organisational policies and procedures relating to documentation are followed.

• Nurses should ensure that their knowledge and skills remain up to date by undertaking ongoing training and continuing education.

• Nurses should have a clear understanding of their scope of practice, should undertake only nursing care that is within that scope, and should record only the nursing care that they deliver.

• Nurses should be respectful of the contribution of their colleagues in the multidisciplinary health team by reading what others document and noting how they document it

• Nurses must maintain confi dentiality with respect to all that is written and discussed about residents and their nursing care.

• Nurses should ensure that everything that is recorded is an accurate and true record of events, and should always be be mindful of how others might interpret what is written In particular, nurses should not record anything that will bring disrepute to residents, nursing colleagues, the management of the organisation, or aged care generally.

• If negative issues need to be noted, nurses should follow proper process in expressing their concerns—through incident reports, staff meetings, or private meetings with authorities.

9 Understanding Nursing Documentation

Nursing practice

Codes of conduct

In most jurisdictions, registered nurses are required to adhere to a code

of professional conduct—‘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 practice with respect to documentation should reflect such

safe, competent nursing care

Professional nurses must ensure that appropriate documentation

is written at all times Nurses must be knowledgeable about, and

competent in, the documentation

process that is in place within their

organisations They should become

change agents in addressing any

areas that cause them concern

Each nurse is responsible for his or her own nursing practice—and documentation is a part of that responsibility

Standards of practice

Nurses are familiar with standards in various aspects of their practice,

but many have not considered the role of standards with respect to

documentation Table 1.1 (page 10) presents suggested ‘benchmark

standards’ for documentation

Holistic nursing practice

Holistic nursing care incorporates a broad range of issues—including

documentation Each aspect of the holistic nursing process has a

corresponding application in documentation, as shown in Table 1.2

(page 12)

Once information has been collected about the range of healthcare issues (as noted in Table 1.2), an analysis of the information must be

undertaken This is followed by the development of a nursing-care plan

that reflects a broad picture of quality holistic nursing care

‘Each nurse is responsible for his or her own nursing practice—and documentation is

a part of that responsibility.’

Nursing Documentation

Table 1.1 Benchmark standards for nursing documentation

A DAPTED FROM N ORRIS (1994)

Quality control Team leader should note quality

improvement opportunities, identify issues, collect data, evaluate data, and take corrective action.

Documentation system, representative, and committee

Scope of

documentation Team members in each clinical care area should clearly define

their group’s function in relation

to documentation, and identify the breadth and scope of the documentation requirements in their area.

Documentation philosophy, policy, and procedures Job descriptions, and duty statements

Key aspects of the

documentation

process

Team members should define the critical components of the documentation system, determine the type of documentation used, note what is used most frequently, who uses what, and why different components are used.

Team members should note any critical incidents that have occurred in relation to documentation.

Continuous improvement program, best-practice principles, and benchmarking

quality-Indicators Team members should identify the

latest documentation indicators from research, journals, and professionals.

Team members should undertake studies to identify indicators for each key aspect of the system as

follows: (i) Structural indicators

(describe the environment, equipment, and qualifications of the

nursing staff involved); (ii) Process

indicators (identify policies and procedures, and thus demonstrate what nurses routinely do in relation to the documentation

process; and (iii) Outcomes

indicators (focus on critical incidents and construct processes

to address the issues identified).

Evidence-based processes Auditing and benchmarking

(continued)

Aspect Actions and standards Application

to review resources, staff education, a particular process,

or an extensive review.

Benchmarking

Data collection Having established internal

benchmarks, the team collects and organises data for each indicator.

Auditing Benchmarking

Data analysis Team analyses data, identifies

patterns, and determines if a problem exists.

Auditing Benchmarking

Taking action Team recommends or initiates

corrective action.

If the corrective action is beyond scope of practice, the team makes recommendation to those who have the authority

to act.

Action plan

Evaluation of

outcome Team monitors and evaluates critical aspects of the action

taken above and ensures continuous improvement is maintained.

Systems adjustments

Communication of

findings Team publishes findings and use these as an education tool for

other clinical areas.

Staff meetings, annual reports, conferences, journal articles, education programs, books

External

benchmarks Team compares documentation with other facilities, encourages

collaboration (rather than competition), and objectifies the documentation process.

Meetings, secondment of staff members, and joint projects

Table 1.1 Benchmark standards for nursing documentation(continued)

11 Understanding Nursing Documentation

Nursing Documentation

Table 1.2 Holistic nursing care and documentation

A UTHORS ’ PRESENTATION

General health status (breathing, circulation,

past history, current health status) Admission form

Clinical measurements and assessment Admission form

Nutritional status (food, fluid) Nutrition assessment

Bowel function record

Social profile

Physiotherapy assessment Manual-handling risk assessment

Social profile

Social profile

Social profile Family, values, and socialisation Admission form

Social profile

Social profile Behavioural assessment

Reflective nursing practice

Reflection on nursing practice in general, and on documentation in

particular, assists nurses to become fully cognisant of their knowledge and

actions

If nurses are honest in their reflections on documentation, this process can be difficult and uncomfortable Such reflection might lead

some nurses to recognise that they must alter the style of documentation

that they have used for a long time Indeed, some nurses find it easier not

to reflect (to avoid facing the necessary changes to their practice), and

some even choose to opt out of the profession completely because the

demands of the documentation process are perceived to be so onerous and

overwhelming

However uncomfortable the process might be, professional nurses have an obligation to reflect on their practice At the very least, such

reflection is an opportunity to ensure that their documentary practice is

up to date with contemporary expectations Reflection also represents a

chance for nurses to look ‘within’ and to get to know who they really are

They must be prepared to confront

and understand the discrepancies

between their own documentation

practice and best practice within the

profession

Reflection allows nurses to look at the documentation process from various angles, and to identify what has worked and what has not

worked Reflection thus provides nurses with an opportunity to become

change agents by engaging in a problem-solving process that fosters

As noted above, reflecting on all documentation issues (even those that seem

insignificant) provides nurses with an opportunity to become change agents

13 Understanding Nursing Documentation

‘It is important that management provides nurses with professional space in which to reflect.’