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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 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: <> email: <>

Nursing Documentation in Aged Care
A Guide to Practice
Edited by Christine Crofton and Gaye Witney
Foreword by Rosalie Hudson



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: <> website: <> 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: <> 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

Dedication and Acknowledgments Foreword Preface About the Authors Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Understanding Nursing Documentation
Christine Crofton and Gaye Witney

1 19 31 45 63 79 97

Clinical Reasoning
Bart O’Brien

Professional Communication
Christine Crofton and Gaye Witney

Nursing Care Plans
Shirley Schulz-Robinson

Progress Notes
Joanne Hope and Pamela Bell

Clinical Pathways
Jenni Ham, Ann-Maree Conners, and Angela Crombie

Documenting Behaviour and Emotion
Felicity Humble

vi Contents

Chapter 8 Chapter 9 Chapter 10 Chapter 11 Chapter 12 Chapter 13 Chapter 14 Chapter 15 Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7 Appendix 8 References Index

Documenting Complementary Therapies
Sue Forster

109 123 137 151 169 181 193 209 249 255 261 267 273 279 285 289 293 299

Documenting Pain Management
Michael Cully

Documenting Restraint
Sue Forster

Incident Reports
Adrian Cross

Documenting Evaluative Criteria
Sue Forster

Documenting Staff Issues
Sue Forster

Effective Design for Documentation
John Collins

A Systems Model for Documentation
Christine Crofton and Gaye Witney

Faecal Incontinence
Janette Williams

Behavioural Management
Robyn Daskein

Victoria Stevenson

Robyn Millership

Stomal Care
Heather Hill

Leg Ulcer Management
Sue Templeton

PEG Nutrition
Patsy Montgomery

Beverly Smith

and professionalism and to the elderly people who share so much of their lives with the nurses who care for them. To Cynthea and Ausmed Publications for having faith in us. To our industry colleagues for support and inspiration over the years and to the many skilled nurses who have influenced us during our careers. resilience. and who have encouraged us in all that we attempt.vii Dedication This book is dedicated to aged-care nurses for their courage. who have supported our passion for aged care. Robert. who have been there when needed. Eleanor. To our family and friends. Acknowledgments To Jim. and for making this book possible. and Zoe. Jacinta. .


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?’.Foreword Rosalie Hudson Documentation has come alive! In Nursing Documentation in Aged Care: A Guide to Practice. The rewards of good documentation are to be found not only in professional pride. The various models of documentation described throughout this book will help to identify the unique details of each resident’s care. The issues are presented in ways that reinforce current good practice. the drudgery and monotony are taken out of an important aspect of nursing that has become. a dreaded necessity. encourage reflection on practice. but also in creating more time for resident care. for many. and offer new ideas to guide improved practice. What does this record convey about the care of this particular resident? Who is . 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.

Each component of documentation is described and distinguished from others—showing clearly how to avoid the duplication evident in contemporary practice. Throughout this book. Evidence of quality leads to expanded knowledge. they also evaluate responses to specific episodes of care and thus learn from one another. This book therefore has enduring qualities. nurses do more than merely record facts and details. 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. It has the potential to influence the whole of aged-care practice.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. Written by people committed to the cause. Good documentation is presented as the key to evidence—not only for legal and regulatory purposes but also for improved professional practice. communication is the cornerstone of effective documentation. the documented record is a profoundly insightful expression of professional holistic care. The practical examples provided will inspire nurses with confidence to try new approaches. To allow for creativity and flexibility to suit local circumstances. In communicating with their colleagues. Helpful case studies based on everyday experience make this an enjoyable book of practical learning. 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. Good communication promotes continuity of care as each person takes up the story—thus capturing the essence of holistic care. fertile ground for future research. . Nursing Documentation in Aged Care: A Guide to Practice challenges nurses to regard quality documentation as a reflection of quality care. there is something in every chapter that will inspire nurses to replace outmoded habits and attitudes with innovation and clarity of purpose. By making explicit the link between the care and the writing. a variety of options is presented. and provides a rich.

and grandchildren. and ethics at the end of life. a graduate diploma in gerontic nursing. Rosalie has presented and published numerous papers and articles internationally on the subjects of spirituality. including 12 years’ experience as the director of nursing of a 50-bed nursing home. adult children. and has contributed chapters to several others. a master’s degree in theology. Rosalie is now a private consultant in aged care and palliative care. Rosalie Hudson Dr Rosalie Hudson is a registered nurse who holds bachelor’s degrees in applied science and theology. dementia. and an honorary senior fellow in the School of Nursing. After a long and distinguished career in clinical and academic nursing. It not only answers immediate needs but also promotes documentation in aged care as a model worthy of wider attention by all nurses. Rosalie enjoys family life with her husband. pastoral care.xi Foreword Nurses will be encouraged by the enduring qualities in this important and timely book. Rosalie edited Dementia Nursing: A Guide to Practice (Ausmed Publications 2003). She has also co-authored two other Ausmed books. University of Melbourne. and a PhD. palliative care. .


In many ways this is understandable.Preface Christine Crofton and Gaye Witney A guide to practice Nurses constantly complain that they have insufficient time for proper documentation. and many aged-care facilities today are understaffed and under-resourced. 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.’ they have time to care or time to write. but do not have time for both. Nursing Documentation in Aged Care: A Guide to Practice is written from . In these circumstances it is hardly ‘The title of the book is carefully surprising that many nurses chosen … nursing documentation feel that caring comes first and in aged care—if performed with pride and professionalism—is documentation comes second—that truly a “guide to practice”. Nursing is essentially about caring.

Comprehensive and accurate documentation shares astute nursing insights. professional. The title of the book is carefully chosen.xiv Preface a different perspective. In this respect. In most jurisdictions. competent nursing care which is responsive to individual. holistic.’ Documentation is more than a tiresome chore. In addition to their ethical and professional responsibilities. nurses are increasingly recognising that documentation is a wonderful opportunity to ‘Documentation is of the utmost record. 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. nurses are recording and communicating information about many important matters. professional. group and community needs’ (ANCI 2000). and reflective. and reflective. reflects the excellence of holistic aged-care nursing. A nurse’s professional practice with respect to documentation should reflect such safe. They have ‘ … a responsibility to the individual. society and the profession to provide safe. competent nursing care. registered nurses are required to adhere to codes of ethics and codes of professional conduct. holistic. . These include (among others): • care needs—the identification and assessment of the needs of those in their care. The purpose of documentation In documenting aged care. 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’. and reflect upon importance as a guide to nursing practice—practice that is ethical. Each nurse is responsible for his or her own nursing practice—and documentation is a part of that responsibility. caring nurses are aware of the personal satisfaction to be gained from holistic and reflective nursing practice. all that is good in nursing. share. and provides a record of the professional and personal support that nurses provide every day to residents and their families.

This book therefore shows how professional documentation allows nurses to share their knowledge. ‘Clinical Reasoning’. nurses. and the subsequent progress of residents. • communication and teamwork—the communication of this information among members of the healthcare team. and continuity of care. 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. and the organisation in which they live and work. The first chapter. thus ensuring teamwork. sets the scene with a general discussion of the major issues. the book then moves on to discuss three important forms of nursing documentation— ‘Nursing Care Plans’. Having canvassed these broad introductory issues. and trends in aged-care nursing. 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. knowledge. ‘Understanding Nursing Documentation’. This is followed by chapters on some selected clinical issues that can provide documentation problems—‘Documenting Behaviour and . 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. observations. shared responsibility. and skills—and thus make a crucial contribution to their own professional lives and to the quality of life of those in their care.xv Preface • care plans and progress notes—the documentation of nursingcare plans to address these needs. The second chapter. • legal requirements—a legal record to protect residents. and ‘Clinical Pathways’. explores how nurses make clinical decisions and canvasses the interaction (and possible conflict) between real nursing experience and administrative documentary requirements. • education and research—the professional sharing of insights. ‘Progress Notes’.

The model presented here puts many of the topics of earlier chapters into an overall context. evidence-based textbook This is therefore more than a ‘how-to-do-it’ workbook on nursing documentation. ‘Documenting Complementary Therapies’. 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. evidence-based textbook ‘More than a ‘how-to-doexplores the issues surrounding it’ workbook on nursing documentation. 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. In doing so. and guides textbook explores the issues nurses in enhancing their professional surrounding documentation. These short case studies present common clinical problems and provide examples of the types of documentation that are appropriate in each case. evidence-based multidisciplinary teams. and ‘Documenting Staff Issues’. With contributions from a range of experts. several case studies are discussed in the appendices. The book then moves onto a consideration of the documentation of wider managerial and administrative issues—‘Incident Reports’. A wide-ranging. .xvi Preface Emotion’. reveals the importance documentation … this wideof effective communication within ranging. The final chapter in the main body of the book draws everything together in a comprehensive ‘Systems Model for Documentation’. cross-referenced index. ‘Documenting Pain Management’ and ‘Documenting Restraint’.’ practice. this wideranging. In keeping with the evidence-based nature of the text. Following the main body of the book. the book concludes with a list of references and a comprehensive. ‘Evaluative Criteria’.

xvii Preface The authors of this book trust that it can help aged-care nurses to see documentation as more than a necessary burden. If performed with pride and professionalism. 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. . Rather. nursing documentation in aged care can truly be a ‘guide to practice’.


He then worked in the public service for 15 years specialising in facilities’ management—including the management of hospitals and aged-care facilities. Having grown up in northern Victoria. Adrian worked in industry for 25 years. Pamela Bell Chapter 5 Pamela Bell is a registered nurse who holds a bachelor of arts degree and a PhD. . Pam is also a registered psychologist who supervises interns undertaking pre-registration requirements at the College of Psychological Practice. Australia). Before becoming an academic nurse. 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. Sydney. 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). dealing with quality assurance and occupational health and safety. and a graduate diploma in ergonomics. a degree in arts. Pam had many years of clinical practice in Victoria and New South Wales.About the Authors Adrian Cross Chapter 11 Adrian Cross holds a diploma in production engineering. Adrian is now a lecturer in aged-services management and occupational health and safety at Victoria University and Kangan Batman TAFE (Melbourne. Pam has an excellent understanding of the problems facing rural health practitioners.

and community nursing clinical pathways for providers of care to veterans. 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. and has recently been appointed to the role of acting group director of nursing at the Bendigo Health Care Group. Christine believes that older people must be valued. diplomas in frontline management and business (community services and health). Her research interests have included (among others): video-conferencing of educational models. training and development. and certificates in gerontology. Chapters 1. This employment has involved him in the design and implementation of a range of records and documents. she has been the director of the Collaborative Health Education & Research Centre (CHERC) of Bendigo Health Care Group (Victoria. post-acute-care programs in regional hospitals. assessment. Christine has been involved in aged care for many years as a registered nurse in various roles—including senior management of aged-care facilities. If this is to be achieved.xx About the Authors John Collins Chapter 14 John Collins holds a diploma in continuing education. For the past five years. and cared for in accordance with the highest professional standards. 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. If aged-care nurses are empowered and confident in their own abilities. 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. He has worked as a senior bureaucrat in a number of educational systems. a regional telerehabilitation project. respected. careplanning in rural areas utilising critical-pathway methodology. Christine believes that documentation must be undertaken effectively and efficiently. Australia). 3. She is currently a nurse educator and is completing her master’s degree in education and training. She is employed as a . positive resident outcomes and excellence in documentation will be assured. Christine Crofton Subject specialist editor. and workplace training. and a master’s degree in education. John is well aware of the importance of well-designed and user-friendly forms for documentation. 15 Christine Crofton is a registered nurse who holds a bachelor’s degree in education and training. a bachelor’s degree in arts. Angela also holds additional qualifications in psychiatric nursing and workplace assessment and training.

As director of her own company. She has extensive clinical. she maintains the company’s continuous-improvement systems across 16 aged-care facilities in Queensland and Victoria (Australia). She is currently undertaking doctoral studies. and Africa. continuous quality . many of which have included the design and development of care pathways in a variety of settings. a graduate diploma in education and training. He is a nurse educator at Ipswich Hospital (Queensland. Angela has been involved in a number of research projects. 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. asthma management in rural Victoria. Australia) with interests in mental-health nursing. In this role. and management services to the aged and community care industry. In his spare time. a bachelor’s degree in applied science (nursing) and a master’s degree in health administration. and managerial experience at senior levels gained from a long nursing career in Europe. For the past ten years Sue has managed her own educational consultancy business. Australia). and aggression minimisation. Some of these projects have included: a regional dementia management strategy. Michael has a particular interest in the mechanics of clinical decision-making under conditions of uncertainty. Sue Forster Chapters 8. continuous quality improvement. Robyn has been working in aged care and has been an aged-care registered nurse adviser since 1987. enjoys the company of his family. Michael Cully Chapter 9 Michael Cully is a registered nurse with a degree in education. health assessments under Medicare schedule items. educational.xxi About the Authors research officer and nurse educator with the Collaborative Health Education & Research Centre (CHERC) of Bendigo Health Care Group (Victoria. Robyn is the national quality assurance manager for the Regis Group. Robyn has specialised in providing education. health surveillance in the elderly using a healthsurveillance screening instrument. and a master’s degree in nursing studies. 12. 10. Australia. Health Care Essentials. Robyn’s PhD studies are directed towards quality outcomes in documenting challenging behaviour in residential aged care. Her special interests include gerontic care. specialising in research and education on aged-care issues. and home and community care best-practice projects. care of older persons. 13 Sue Forster completed her general nurse training in the Queen Alexandra Royal Naval Nursing Service in the UK and abroad. he listens to classical music.

and quality and accreditation coordinator. Before specialising in aged 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. Joanne is passionate about continuous quality-improvement processes and excellent care outcomes for aged-care residents. and human-resource management.xxii About the Authors improvement. She has also been a consultant with the World Health Organization. Her past positions in aged care have included executive nurse advisor. She is also a life member of the Australian Association of Stomal Therapy nurses and the World Council of Enterostomal Therapy. doctors. Joanne Hope Chapter 5 Joanne Hope graduated as a general nurse from the Royal North Shore Hospital (Sydney. and evaluation of clinical pathways in acute and rehabilitation settings. 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 and her colleagues at CHERC have demonstrated that clinical pathways can be implemented successfully for patients with complex needs. 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. director of care. Australia) in 1973. She has lectured extensively and has written papers for nurses. . Jenni has extensive experience in the design and implementation of clinical pathways. 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. Joanne is currently working as a nurse administrator in the agedcare sector. Jenni’s work has achieved national recognition. Her research projects have included the design. allied health personnel. 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). implementation. as demonstrated by frequent invitations for her to present at workshops and conferences. Since 1994. Heather has been involved in clinical practice and education in stomal nursing since 1981. and the design and implementation of clinical pathways in smaller rural hospitals. Joanne held the position of principal lecturer of nursing at La Trobe University (Victoria. deputy director of nursing and education. Australia). and laypeople. She also holds a diploma in nurse education and a master’s degree in education.

and support. and ward management. 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. Robyn was a recipient of a Victorian Nurses Care Award in 1994. Australia). intensive care. and education. rehabilitation. 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. Throughout this time she has been enriched by an array of experiences with the elderly. intensive care. Felicity Humble Chapter 7 Felicity Humble is a registered nurse and registered psychiatric nurse who holds bachelor’s and master’s degrees in nursing. accurate. and a diploma in applied science (advanced psychiatric nursing). She is currently a nurse consultant in palliative care at the Peter MacCallum Cancer Institute. Robyn has worked in palliative care as a nurse consultant for more than 15 years. administration.xxiii About the Authors She believes that timely. and has worked with aged patients in acute admission. Robyn is passionately committed to providing excellence in symptom control for patients with terminal illnesses. She is co-founder and consultant . Australia). She has also had several years’ experience working with postgraduate psychiatric nurses. encouragement. and secure settings. registered midwife. Patsy Montgomery Appendix 7 Patsy Montgomery is a registered nurse. St Vincent’s Hospital and Caritas Christi (both Melbourne. She believes that most people can achieve what seem to be impossible goals if they are provided with optimal symptom control. She also holds a certificate in palliative care. and stomal therapist who holds a bachelor’s degree in educational studies. and comprehensive nursing documentation is vital to achieving such outcomes. Her background is diverse including clinical practice. Robyn Millership Appendix 4 Robyn Millership is a registered nurse and registered midwife who holds diplomas in nursing education. Felicity fell in love with this area of nursing and has remained passionately interested in psychiatric nursing ever since. Felicity is currently a psychiatric nurse educator working with nursing staff at Barwon Health Community and Mental Health (Geelong. knowledge. 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.

book chapters. and is frequently invited to contribute to the professional development of aged-care nursing through participation in seminars. Bart has edited. their families. Belair (South Australia). Shirley’s research interests include community-health nursing. This includes information and help for managing enteral tubes and equipment. lectures. For 19 years she worked in nurse education. and pumps. Patsy also provides education and practical ‘hands-on training’ for gastrostomy-fed people and carers.xxiv About the Authors for the Gastrostomy Information Support Service. and quality coordinator. consultant. developmental disability nursing. Shirley has been chairperson of the Hunter Chapter of the Royal College of Nursing. Her current research has demonstrated that much of the work undertaken by nurses is hidden. Bart has contributed to the development of a practice-based model for aged-care nursing. including terms as the clinical director and assistant dean in the Faculty of Nursing at Newcastle University (Australia). health policy. president of the New South Wales Community Health Association. workshops. and the coordinator and clinical nurse consultant for the Abbott Nutrition Service. His PhD thesis was on the subject of nursing praxis—what nursing does to improve care and outcomes for residents. and information regarding supplies of formula. a member of the Public Health Research and Development Committee of the National Health and Medical Research Council . equipment. and community health. As a result of this and other research. Australia. Bart has worked in a variety of position in residential aged care since 1986—including educator. women’s health. written. advice about methods of feeding and nursing care. Patsy’s role is to provide a support service for tube-fed people. and co-authored a number of books and monographs. and is currently the quality coordinator at the James Brown Memorial Trust. Victoria (Australia). and research projects. medical and surgical nursing. Australia. refereed journal articles. and that it is commonly attributed to the efforts of other professions. and research reports. president of the Peninsula Ostomy Association (Melbourne. Australia). videos. continence advisor. 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. Bart O’Brien Chapter 2 Bart O’Brien is registered nurse who holds a bachelor’s degree and postgraduate qualifications in nursing. consultations. and collaborative health-promotion strategies with patients and communities. He is a member of the Royal College of Nursing. assistant director of nursing. and their carers when patients are discharged from hospital into the community. and literature for healthcare professionals. She also provides in-service training. clinical nurse consultant.

and a certificate in orthopaedic nursing. Beverly has had varied experience as a clinical nurse specialist and manager in Melbourne (Australia)—at first in rehabilitation. she has developed a particular interest in documentation. Victoria speaks frequently at seminars and conferences and has co-authored and produced a video ‘Diabetes—Understanding It’. She is a clinical nurse consultant and advanced wound specialist with the Royal District Nursing Service of South Australia. Victoria Stevenson Appendix 3 Victoria Stevenson is a registered nurse and registered midwife who holds a graduate diploma in health education. As a result of these experiences. and later in aged-care services. Beverly Smith Appendix 8 Beverly Smith holds a bachelor of nursing. a clinical tutor with the University of Adelaide. staff education. and postgraduate diplomas in gerontological nursing and aged-care services management. and a member of the South Australian Wound Management . a certificate in hyperbaric nursing. Australia. Victoria is a fellow of the Royal College of Nursing. a certificate of rehabilitation and extended care. 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. and participation in professional community services. Her role includes promotion of nursing practice in this speciality area. She is a past vicepresident 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. and a member of the New South Wales Nurses Tribunal. collaboration with health providers to provide education for people with diabetes. creative. and her work as an external aged-care standards agency assessor.xxv About the Authors (Australia). She began part-time private practice many years ago. Beverly believes that documentation should be succinct. 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. Shirley retired from Newcastle University in 2003 to devote more time to writing and consulting. She is completing her master’s degree in nursing. and streamlined to focus on maximising the life opportunities of residents. Australia). Sue frequently conducts wound-management education for nurses in a variety of settings and has published and presented at local and national forums. Sue Templeton Appendix 6 Sue Templeton is a registered nurse who holds a bachelor’s degree in nursing.

the South Australian Vascular Nurses Society. and workplace assessment. 15 Gaye Witney is registered nurse who holds a bachelor’s degree in education. and business (community services and health).xxvi About the Authors Association. 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. 3. Janette Williams Appendix 1 Janette Williams is a registered nurse who holds a master’s degree in nursing bioethics. 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. training and development. Janette is immediate past chairperson of the Australian Nurses for Continence. . Janette has worked as a continence consultant for more than 12 years. Gaye Witney Subject specialist editor. nursing-care plans and progress notes. personal skills development. Management of Faecal Incontinence. management. training. She is currently undertaking studies towards her master’s degree in education. and the Australian Council of Community Nursing Services. industrial education and training. and certificates in gerontic nursing. Chapters 1. 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. She is the author of the Ausmed publication. frontline management. diplomas in primary education.

proactive.’ provided for all nursing staff. Many time-consuming and costly ‘documentation issues’ ‘Poor documentation can put can be avoided if a clear vision and accompanying guidelines are residents at risk and can jeopardise funding to the organisation. and must ensure that processes are in place to guide and support them to fulfil these requirements. inconsistent. ambiguous. Poor documentation can put residents at risk and can jeopardise funding to the organisation. Time and . and definite about what it requires of nurses. and reactive documentation.Chapter 1 Understanding Nursing Documentation Christine Crofton and Gaye Witney Introduction Nursing documentation is vitally important. it is essential that nurses understand the documentation requirements of the organisation in which they work. 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. An organisation must therefore be positive. To avoid incomplete.

Registered nurses accept the professional responsibility and trust inherent in their role. Glossary of key terms Documentation Documentation can be defined as a written record of proceedings.2 Nursing Documentation commitment will be required if the organisation is to ensure that staff members are informed and educated with respect to its expectations. Values develop from the influence of significant people and events through life and can affect all aspects of a nurse’s practice. It is a collection of documents that provides an account of the care delivered by the multidisciplinary healthcare team. including how he or she regards the issue of documentation. and demonstrates a commitment to the documentation process. The Box below contains a glossary of some key terms. Leadership Leadership is a commitment to assisting others to feel. Key terms Before exploring the subject in greater detail. Ethics Ethics are principles that act as a guide to decision-making for nurses involved in the documentation process. it is helpful to establish an understanding of the terminology used in this important subject. A leader is someone who has a vision. and are required to adhere to professional codes of conduct. Standards of practice Standards of practice are expectations of professional nursing conduct. takes action. They are the ‘silent factors’ that influence and shape a nurse’s practice. or behave in a certain way. . Values Values are the personal rules by which nurses live. think.

• to assist in research and the development of new ways of delivering nursing care. and is essential to the appropriate and accurate management of people in care. and must therefore make sense and have meaning if it is to be a communication tool for all involved. Documentation is essentially about communication. it should be noted ‘Documentation is essentially that documentation has moved from about communication. . and the requirements of the organisation. and • to meet funding requirements by providing all required statutory information. Purposes of documentation The purposes of documentation are: • to act as a communication tool by enabling clear. • to act as an educational tool.3 Understanding Nursing Documentation Importance of documentation Nursing documentation is central to quality nursing care. • to be a legal record to protect residents. It is essential to have a documentation system in place. duty of care.’ 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). and accurate documentation ensures that appropriate and consistent nursing care is planned and implemented in accordance with medical diagnoses. • to ensure continuity of care with respect to residents’ nursing care needs. concise. nurses. In instituting such a system. The two models are complementary. All those involved in the care of residents must be aware of their responsibilities. and the organisation. and relevant information to be exchanged among those involved in the care of residents.

The minimum requirements for documentation are the imposed documentation processes linked with a funding model. • be flexible. • take responsibility. Leaders need to: • stimulate colleagues. • be enthusiastic. • seek input from others (and value the information). • remain focused. a ‘If the leadership vision goes beyond positive environment can be mere funding requirements. • be positive about managing the documentation process. In these circumstances.4 Nursing Documentation Leadership Leadership is required within an organisation when setting the standards for documentation.’ excellence are set and in which the leader can become a true agent and facilitator of change. • demonstrate commitment. • create a learning culture. are inspired. • have vision. • take action. and negative attitudes can easily develop. nurses become involved. and develop confidence in themselves and the importance of nursing documentation. but many organisations are showing leadership by choosing to go beyond these minimal requirements. a created in which standards of positive environment can be created. • overcome obstacles. . 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. If the leadership vision goes beyond mere funding requirements. • listen actively.

and • be aware of their own strengths while seeking support and guidance as appropriate. • Date. nurses are required to uphold a duty of care. records can become legal documents in a court of law. time. residents can be quoted when appropriate. • Legibility—what is written must be legible to all members of the multidisciplinary healthcare team. Legal issues Various statutory requirements dictate the professional practice of registered nurses in all respects—including nursing documentation. Legal constraints on documentation Precise legal requirements with respect to documentation vary from jurisdiction to jurisdiction. Precise responsibilities and constraints vary from jurisdiction to jurisdiction. • Permanency—notations must be made in permanent blue or black ink. factual. concise. time. but some of the legal principles that apply include: • Confidentiality—once information is collected. and designation—whenever a record is made. and all nurses must be aware of the implications of this with respect to documentation. nurses should not make assumptions or give personal opinions. it must be protected. • Timing—best practice requires that the notations be made in the record as things happen (rather than being recorded some time after the event). the date. documentation should be specific. (continued) . As professionals. accurate. and nursing staff designation must be recorded to ensure that the writer is identified and that an accurate sequence of events is recorded. and evidence-based.5 Understanding Nursing Documentation • push the boundaries. mistakes can be made if team members are unable to read entries in the notes. • Objectivity—facts should be recorded. but the Box below lists some of the important principles to be observed.

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. the record can then be destroyed by shredding. many facilities now have a recognised list of abbreviations to be used by all team members. • Blank spaces—no blank spaces are to be left after the documentation is completed. • Personal responsibility—nurses should never document for someone else. and nurses must be aware of these constraints if requests are made for access. and the notation should be initialled and dated. nor sign another person’s name. it is inappropriate to fail to document an incident because ‘that is how the resident always is’. and ‘whiteout’ should not be used. The fundamental ethics of nursing dictate that nurses promote and restore health.6 Nursing Documentation (continued) • Abbreviations—a consistent set of abbreviations should be used to avoid confusion. it might be appropriate to draw a line through the space to the end of the line. the word ‘error’ should be entered. in most cases. prevent illness. if the line has not been filled. errors should not be erased. with access being limited only to authorised people. a line should be drawn through the error. For example. 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. . Ethics The ethics of documentation can be challenging for nurses. • Access—it is essential that all appropriate legal constraints be followed with respect to access to records. • Corrections—if an error is made. nursing documentation is a legal record. • Destruction—a record must be kept for a specific time (as per local regulations) after the last admission or death of a resident.

To avoid these sorts of problems. his or her satisfaction with the situation will decrease and can cause increasing discontent and poor morale in the workplace.7 Understanding Nursing Documentation Nurses and the organisation need to be open. Conflict between various team members regarding documentation can have adverse effects on residents and can cause ethical issues for nurses. The ethical demands on nurses . If not. and images by which nurses judge the outer world of everyday life and human behaviour. p. and willing to discuss ethical documentation issues as they arise.’ act on consciously and repeatedly’. it will affect the quality of care. It is inevitable that some people will be somewhat dissatisfied with the decisions reached. A suggested set of such guidelines is presented in the Box on page 8. Once a decision has been made. This must be acknowledged and addressed. but with professional understanding and healthy debate. dreams. ideals. appropriate decisions will be reached. and that we judge what is important to them. As Hall (1995. Values thus affect everything in professional life. 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’. and dignity of both residents and staff. If a nurse continues to work in this environment. a set of ethical guidelines with respect to documentation should be observed by the organisation. but this is part of professional life and personal growth. all nursing staff must be informed of the outcome and the documentation requirements that will result from that decision. 21) observed: ‘Values are ‘Values are the filter through the ideas that give significance to our which nurses view the world and lives. Consensus should always be sought on contentious ethical issues. choices. Conflict can occur. that are reflected through the priorities that we choose. Values Values make up the inner world of personal hopes. Values are thus the filter through which nurses view the world and by which they judge what is important to them and society. honest. including nurses’ responses to documentation requirements.

or private meetings with authorities. should undertake only nursing care that is within that scope. politics. or social status. staff meetings. • Nurses should respect the lives. • Nurses must maintain confidentiality with respect to all that is written and discussed about residents and their nursing care. and if nurses fail to recognise or respond to conflicts between their own values and the ethical requirements put upon them. and rights of all residents. nursing colleagues. dignity. and should always be be mindful of how others might interpret what is written. • 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. the management of the organisation. the following ethical guidelines are suggested. Ethical guidelines for documentation To ensure the highest standards of professional practice in documenting nursing care. • Nurses should acknowledge the values. gender. and spiritual beliefs of all residents.8 Nursing Documentation with respect to documentation are demanding (see above). age. irrespective of ethnic origin. • 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. In particular. nurses should follow proper process in expressing their concerns—through incident reports. and significant others. their familes. their documentation practice will suffer. or aged care generally. and should record only the nursing care that they deliver. customs. • Nurses should have a clear understanding of their scope of practice. • If negative issues need to be noted. . nurses should not record anything that will bring disrepute to residents. • Nurses should ensure that everything that is recorded is an accurate and true record of events. • Nurses should maintain the dignity of residents at all times in terms of what they write about residents.

2 (page 12). A nurse’s practice with respect to documentation should reflect such safe. This is followed by the development of a nursing-care plan that reflects a broad picture of quality holistic nursing care. group and community needs’ (ANCI 2000). Table 1. They should become practice—and documentation is change agents in addressing any a part of that responsibility. Professional nurses must ensure that appropriate documentation is written at all times. an analysis of the information must be undertaken. competent nursing care which is responsive to individual. Each aspect of the holistic nursing process has a corresponding application in documentation. Holistic nursing practice Holistic nursing care incorporates a broad range of issues—including documentation.’ areas that cause them concern. Nurses must be knowledgeable about.1 (page 10) presents suggested ‘benchmark standards’ for documentation. and competent in.2). as shown in Table 1. competent nursing care.9 Understanding Nursing Documentation Nursing practice Codes of conduct In most jurisdictions. Each nurse is responsible for his or her own nursing practice—and documentation is a part of that responsibility. registered nurses are required to adhere to a code of professional conduct—‘a responsibility to the individual. society and the profession to provide safe. Standards of practice Nurses are familiar with standards in various aspects of their practice. Once information has been collected about the range of healthcare issues (as noted in Table 1. but many have not considered the role of standards with respect to documentation. . the documentation ‘Each nurse is responsible process that is in place within their for his or her own nursing organisations.

and why different components are used. Team members should note any critical incidents that have occurred in relation to documentation. determine the type of documentation used.1 Benchmark standards for nursing documentation ADAPTED FROM NORRIS (1994) Aspect Quality control Actions and standards Team leader should note quality improvement opportunities. and thus demonstrate what nurses routinely do in relation to the documentation process. and benchmarking Indicators Evidence-based processes Auditing and benchmarking (continued) . and professionals. and procedures Job descriptions. equipment. (ii) Process indicators (identify policies and procedures. note what is used most frequently.10 Nursing Documentation Table 1. evaluate data. and committee Documentation philosophy. Team members should undertake studies to identify indicators for each key aspect of the system as follows: (i) Structural indicators (describe the environment. Team members should identify the latest documentation indicators from research. who uses what. identify issues. Team members should define the critical components of the documentation system. representative. policy. and identify the breadth and scope of the documentation requirements in their area. Application Documentation system. Team members in each clinical care area should clearly define their group’s function in relation to documentation. and duty statements Scope of documentation Key aspects of the documentation process Continuous qualityimprovement program. journals. and take corrective action. best-practice principles. and qualifications of the nursing staff involved). collect data. and (iii) Outcomes indicators (focus on critical incidents and construct processes to address the issues identified).

secondment of staff members.1 Benchmark standards for nursing documentation (continued) Aspect Internal benchmarks Actions and standards Team leaders establish internal benchmarks to measure documentation compliance. and objectifies the documentation process. the team collects and organises data for each indicator. Team recommends or initiates corrective action. identifies patterns. and determines if a problem exists. such validation identifies processes not being followed and might indicate a need to review resources. annual reports. a particular process. or an extensive review. Application Benchmarking Data collection Auditing Benchmarking Data analysis Auditing Benchmarking Action plan Taking action Evaluation of outcome Systems adjustments Communication of findings Staff meetings. Having established internal benchmarks. Team publishes findings and use these as an education tool for other clinical areas. staff education. conferences.11 Understanding Nursing Documentation Table 1. and joint projects External benchmarks . education programs. Team compares documentation with other facilities. the team makes recommendation to those who have the authority to act. journal articles. Team analyses data. If the corrective action is beyond scope of practice. books Meetings. encourages collaboration (rather than competition). Team monitors and evaluates critical aspects of the action taken above and ensures continuous improvement is maintained.

past history.2 Holistic nursing care and documentation AUTHORS’ PRESENTATION Nursing care General health status (breathing. and socialisation Coping/grieving/losses Sexuality Self-concept Spiritual health Stress management Sensory function . current health status) Health management Clinical measurements and assessment Nutritional status (food. values. fluid) Bladder and bowel function Hygiene and grooming Skin integrity and wound care Exercise and activity Documentation application Admission form Admission form Admission form Nutrition assessment Elimination assessment Bowel function record Activity of daily living assessment Social profile Skin assessment Mobility assessment Physiotherapy assessment Manual-handling risk assessment Sleep assessment Social profile Mini-mental status Social profile Pain assessment Risk assessment Social profile Admission form Social profile Admission form Social profile Behavioural assessment Sexual health assessment Depression assessment Social profile Behavioural assessment Visual and hearing assessment Rest and sleep Cognitive function Pain Safety and protection Family.12 Nursing Documentation Table 1. circulation.

Reflection thus provides nurses with an opportunity to become change agents by engaging in a problem-solving process that fosters accountability. Praxis As noted above. this process can be difficult and uncomfortable. Staff ratios and the demands of cost-efficiency often mean that nurses have little time to reflect in the work environment. . professional nurses have an obligation to reflect on their practice. They must be prepared to confront and understand the discrepancies ‘It is important that management between their own documentation provides nurses with professional space in which to reflect. and on documentation in particular. such reflection is an opportunity to ensure that their documentary practice is up to date with contemporary expectations.’ practice and best practice within the profession. Reflection allows nurses to look at the documentation process from various angles. Reflection also represents a chance for nurses to look ‘within’ and to get to know who they really are. If nurses are honest in their reflections on documentation. some nurses find it easier not to reflect (to avoid facing the necessary changes to their practice). At the very least. 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. Indeed. assists nurses to become fully cognisant of their knowledge and actions. Such reflection might lead some nurses to recognise that they must alter the style of documentation that they have used for a long time.13 Understanding Nursing Documentation Reflective nursing practice Reflection on nursing practice in general. and to identify what has worked and what has not worked. reflecting on all documentation issues (even those that seem insignificant) provides nurses with an opportunity to become change agents. It is important that management provides nurses with professional space in which to reflect. However uncomfortable the process might be.

This process is called praxis. and provide resources to enable ‘Management has an obligation them to document appropriately. and should support them in their efforts to do so. support them in their efforts to do so. including lateral thinking about changes and new processes that might be required for a better outcome. • knowledge in action—that is. This involves four phases (Schon 1987): • knowing in action—that is. Management has an obligation to ensure that nurses fulfil their responsibilities with respect to their professional duty of care and codes of conduct. Management must develop policies to guide nurses in their practice. thinking back on the whole process to see if required documentation processes have been followed and whether desired outcomes have been achieved. Management issues that can arise with respect to documentation include problems with: . thinking about the documentation process that is taking place.14 Nursing Documentation To enable this to occur. nurses must engage in the process of critical reflection and then act upon this reflection.’ if desired documentation outcomes are to be achieved. to ensure that nurses fulfil their This management responsibility responsibilities … and should can be delegated. explaining how to do the documentation and what it involves. clear guidelines must be in place to assist those who have been delegated the responsibility. • reflecting in action—that is. facilitate education to assist their understanding of documentation. the actual doing of the documentation. However. Management issues The organisation is obliged to implement the standards of documentation and to make a concerted commitment to support the process. and • reflection in action—that is.

• qualifications of nursing staff.’ ensure that all nurses are aware of their responsibilities in this regard.15 Understanding Nursing Documentation • language. Management should gaps in the nursing-care plan. • documentation not being performed. It might be necessary to ensure that a ‘documentation resource’ is available at all times for nursing staff—including a dictionary and a glossary listing the meaning and interpretation of key words and phrases. and forms of expression. Confusion can arise in multidisciplinary teams if there is uncertainty regarding the documentation responsibilities of various members of the team. levels of experience. Each of these is discussed below. . as should any gaps in the nursing-care plan ‘Anything out of the ordinary in relation to the changing needs should be recorded. and who has responsibility for which aspects of the documentation process. Language. and forms of expression Differences in documentation create confusion. Anything out of the ordinary should be recorded. English as a second language and literacy capability can also be an issue. and staff skills mix. as should any of residents. jargon. It is important that all members of the team understand their scope of practice within the team. and • government regulation. This can be overcome by taking care to establish accepted uses of jargon terms and abbreviations within the organisation. • attitudes of nursing staff to documentation and time-management skills. jargon. Documentation not being performed Contemporary nursing requires all nursing staff to document any changes in the condition of residents and any alteration in their nursingcare plans.

• Some experienced and able nurses might take it upon themselves to change the system without full consultation with colleagues and without regard to organisational policies and structure. If there are varying levels of documentation knowledge and skill among members of the nursing staff.’ adverse outcomes for residents. or if they are reluctant to hold others accountable for their standards of documentation. Nurses constantly complain that they have insufficient time for proper documentation. nurses with a higher level of competence are expected to undertake all the documentation. • Some experienced and able nurses might refuse to share their expertise with others. • In some organisations. and this can lead to a perception that colleagues with lesser skills are avoiding their responsibilities—thus creating tension within the team. Staff education is the key to ensuring that all documentation processes are followed. conflict can arise.16 Nursing Documentation Qualifications of nursing staff. if they have difficulty delegating responsibility to others. levels of experience. Education about time management will assist nurses in discharging their responsibility to include documentation as . Negative attitudes—which perceive documentation as a burden rather than as a positive process that enhances ‘Nurses constantly complain that nursing care—can diminish the they have insufficient time for quality of documentation and have proper documentation. • The increasing use of casual and agency staff members (who might have less commitment to organisational processes) can lead to outright disregard for the documentation process. Attitudes of nursing staff to documentation and timemanagement skills Nurses’ attitudes are crucial to the success of the documentation process. and staff skills mix Problems can occur if nurses do not understand the requirements of documentation.

values. their efficiency will be improved.’ that residents are not placed at risk and that funding to the facility is not placed in jeopardy. legal issues. ethics. Management must be visionary and have clear guidelines to ensure that all nurses are aware of their responsibilities in relation to ‘High-quality documentation documenting nursing care. and good management. Conclusion The documentation process involves leadership. Government regulation Both nursing staff and the organisation can feel that over-regulation is an issue. their complaints (that they do not have enough to document without compromising resident care) will be alleviated. This is best done by emphasising that the real focus of documentation is positive outcomes for residents. standards of practice. Moreover. reflective practice. Highensures that residents are not placed quality documentation ensures at risk and that funding to the facility is not placed in jeopardy. If nurses are supported with appropriate resources and organisational processes. Management must promote a positive attitude to documentation to ensure that the requirements of government are met. holistic nursing. .17 Understanding Nursing Documentation an essential part of the nursing process.


Chapter 2

Clinical Reasoning
Bart O’Brien

Clinical reasoning is the process of reaching clinical conclusions through professional judgment, knowledge, and experience. Clinical reasoning also involves an understanding of the politics of clinical practice. Nurses in residential aged care need to understand the regulatory, political, and social customs that dictate the care that is provided, when it is provided, and who provides it. Clinical reasoning thus helps nurses ‘Clinical reasoning is the key working in aged care to identify and to successful documentation.’ access the resources necessary to provide the elderly with the best available standards of care, as well as providing a means of identifying and documenting best practice in care delivery. Clinical reasoning is the key to successful documentation because it helps nurses to decide what needs to be documented and in what detail.

The nature of clinical reasoning
Three theories
Clinical reasoning is ‘ … the way that [nurses] collect, store, retrieve and use information’ (Greenwood 1998a, p. 110). Clinical reasoning has been

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the subject of extensive investigation for more than 40 years. During that time there have been several interpretations of the concept and how it works, and consensus has been difficult to achieve (Greenwood 1998b). Three ways of describing clinical reasoning are (Greenwood 1998b): • decision theory; • information-processing theory; and • skills-acquisition theory. Each of these is discussed below. However, whatever theory (or combination of theories) best describes clinical reasoning, the practical process is eventually dependent on nurses’ understanding of those in their care.
Decision theory According to decision theory, clinical reasoning involves understanding the relationships among various possibilities. Decision theory is based on experience—if something happened previously it is probable that it will occur again under similar ‘Decision theory is based on circumstances. An example is the experience—if something so-called ‘sundowner syndrome’— happened previously it is probable whereby people with dementia often that it will occur again under exhibit certain predictable behaviours similar circumstances.’ in the early evening. By reasoning in this way, nurses can predict with some certainty what a particular resident will do, what provokes the person to do it, and what nursing intervention might alter the behaviour. However, some behaviours do not have such an obvious and predictable pattern. Information-processing theory Information processing uses a sequence of thoughts, recollections, and interpretations to create an understanding of what is occurring. Nurses observe a person behaving in a certain manner and draw on their nursing experience and knowledge to make sense of the event. Acting on their interpretation, nurses interact with the person to alter the behaviour. As they try various options, nurses thus accumulate more knowledge and experience.

21 Clinical Reasoning

Three theories of clinical reasoning
There have been several interpretations of clinical reasoning and how it works. Three ways of describing clinical reasoning are: • decision theory; • information-processing theory; and • skills-acquisition theory. In addition to the insights to be gained from these theories, the practical process of clinical reasoning is eventually dependent on nurses’ understanding of those in their care.

Information-processing theory is different from decision theory in that it places equal value on reasoning and experience. Whereas decision theory assumes that nurses know the answers before they start, information-processing theory assumes ‘Information-processing that feedback about the nursing strategies theory places equal value on that have been implemented is essential to reasoning and experience.’ validating the most appropriate approach.
Skills-acquisition theory The skills-acquisition theory of clinical reasoning was developed by the Dreyfus brothers in the late 1970s, and was applied to nursing by Benner (1984). According to this theory, the more skilful and experienced a nurse is, the more likely he or she is to use personal experience to drive clinical decision-making. For example, an inexperienced nurse has little personal knowledge of what constitutes inappropriate or ‘According to skills-acquisition theory, challenging behaviour. Such a skilful and experienced a nurse is nurses therefore tend to follow more likely to use personal experience the directions and nursing-care to drive clinical decision-making.’ plans set by others, rather than acting on their own initiative. As a relationship develops between a nurse and a particular person, the nurse learns what behaviours are likely to occur, under what circumstances, and what to do about them. According to skills-acquisition

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theory, clinical reasoning improves as nurses acquire greater skills. These are acquired by implementing nursing strategies that have worked before, thus allowing nurses to manage people more easily.

Nurses’ understanding of those in their care
The three theories described above make sense of the way in which nurses process the amount of information they have to deal with on a shift-byshift basis. At various times, each theory has had its following, and each has its applications in particular ‘The key to effective nursing care is circumstances—depending on nurses’ developing a comprehensive the knowledge and experience understanding of those in their care.’ of the nurse who makes clinical decisions. Taken together, the three theories discussed above make sense of some aspects of clinical reasoning, but they do not provide a full explanation of the process. A fourth approach complements these theories by suggesting that the key to effective nursing care lies with nurses’ developing a comprehensive understanding of those in their care. The essential parts of such a comprehensive knowledge base are (Radwin 1996): • nurses’ knowledge of the particulars that set individuals apart from others with the same diagnosis; • nurses’ knowledge of: (i) residents’ responses to treatments; (ii) their routines and habits; (iii) their coping resources; (iv) their physical capacities and endurance tolerances; and (v) their body type and characteristics; • nurses’ understanding of each person’s current status together with that person’s baseline responses to specific treatments and interventions; • nurses’ awareness of how people perceive situations in which they find themselves (thus assisting nurses to understand and deal effectively with residents’ concerns); and • nurses’ experience of residents’ needs and responses to previous nursing care.

23 Clinical Reasoning

Understanding those in care
In addition to the three theories of clinical reasoning discussed in this chapter, the key to effective nursing care lies with nurses’ developing a comprehensive understanding of those in their care. This depends on nurses’ awareness of: • the particulars that set individuals apart from others with the same diagnosis; • residents’ responses to treatments, their routines and habits, their coping resources, their physical capacities, and their body type and characteristics; • each person’s current status and responses to specific treatments; • how people perceive situations in which they find themselves; and • residents’ needs and responses to previous nursing care.

To communicate their understanding of those in their care, nurses require a framework that allows them to explain to each other what has occurred and what actions have been taken. The 24-hour-a-day nature of nursing means that teams of nurses are involved in the care of ‘Documentation that reflects group experience communicates a richer any given person. Documentation understanding of a person’s needs that reflects group experience and than that of any individual nurse.’ group observations communicates a richer and more comprehensive understanding of a person’s needs than that of any individual nurse. If these shared understandings are clearly documented, any nurse can access information collected from multiple experiences without having to interrupt other nurses to obtain information verbally. A reluctance to interrupt others can mean that a nurse might work without the knowledge and experience of colleagues who have gone off duty. Collecting the information needed for decision-making is continuous and cumulative in the ‘real world’ of clinical practice. Rarely is all the information available at the time it is needed, so nurses start with what seems reasonable and continually validate their knowledge base. They use feedback from residents and their peers, as well as other resources in the

24 Nursing Documentation

clinical setting—provided that this information can be sourced within a meaningful timeframe (Greenwood 1998b).

Politics of clinical reasoning and documentation
Nurses must consider the environment or context in which clinical reasoning takes place. Health care is ‘political’, and it is costly to provide services. There are therefore many people and authorities who are keen to see that nursing care is providing value for the money. This social monitoring is readily evident in residential aged care—which costs societies around the world huge sums of money every year. Documentation in residential aged care is thus a means of accounting for the cost of providing nursing care, as well as recording and communicating the nursing care that is given. Best practice requires nurses to have knowledge and ‘Factors other than residents needs understanding of the aged care can (and do) influence how care is industry as well as of the needs communicated and recorded.’ of individual residents. This does not mean that nurses must be directly involved with the politics of aged care, but it does mean that nurses who document must be aware that factors other than residents needs can (and do) influence how care is communicated and recorded.

Conflicts between clinical reasoning and documentation
Theoretical plans and clinical experience
Conflicts can arise between clinical reasoning and the demands of nursing documentation. In particular, nursing-care plans are a potential source of conflict. The following sorts of problems can arise: • experienced nurses can consider that the care given in accordance with written nursing plans is of lesser quality than that provided by an experienced nurse who follows his or her clinical reasoning; • nurses can feel constrained to follow nursing plans against their better judgment;

25 Clinical Reasoning

• it is difficult to write a care plan that is appropriate to all members of the nursing team; • documentation can be perceived as an administrative requirement that takes up valuable time; and • theoretical nursing models can be perceived as being irrelevant. Each of these is discussed below.
Lesser quality than clinical reasoning

In many instances, experienced nurses can consider that the care given in accordance with written nursing plans is of lesser quality than that provided by an experienced nurse who follows his or her clinical reasoning. Compared with a nursing ‘Care given in accordance with care plan (NCP), an experienced written nursing plans can be of nurse can initiate actions that are lesser quality than that provided by ‘more immediately relevant [and] an experienced nurse who follows more strategic and farsighted’ than clinical reasoning.’ an NCP. The experienced nurse is also able to intervene in ways that reduce ‘anxiety and agitation in ways more ingenious than those suggested by the NCP’ (Aidroos 1991, p. 179).
Constrained to follow nursing plans

The difficulty with NCPs is that nurses can feel constrained to follow them—even though autonomous thinking and practice would actually be in the better interests of patients. NCPs can be used to satisfy organisational and professional expectations, rather than being used to direct nursing care (Aidroos 1991). Indeed, concerns of this nature led the American Joint Commission on Accreditation of Healthcare Organisations (JCAHO) to remove NCPs from its list of required documentation (Brider 1991).
NCPs inappropriate to all nurses

It is difficult to write an NCP that is appropriate to all members of the nursing team. NCPs written for a novice or an inexperienced nurse can seem ‘wordy’ to a proficient nurse and redundant to an expert nurse.

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This is not a problem if nurses of similar experience are involved in a team. In these circumstances, it is possible to develop a style of clinical documentation that has relevance to everyone—and which is therefore used, valued, and maintained. However, in residential aged care there is often a spread of experienced and inexperienced staff members, and it is likely that competent, proficient, and expert nurses will be responsible for writing NCPs for staff members who have significantly less knowledge and experience. In these circumstances, a proficient or expert nurse can become frustrated with a tedious exercise that is apparently aimed at compliance with regulatory requirements, rather than directing handson staff. In addition, there is a risk that the documentation can miss its intended target—by being too detailed for the staff members who are supposed to follow it.
Administration taking up care time

Documentation can be perceived primarily as an administrative requirement that takes up valuable time that might have been otherwise spent on resident care. This is probably the most common complaint about NCPs among aged-care nursing staff.
Irrelevant theoretical framework

Even if documentation does address clinical issues, the theoretical nursing model framework in use can be perceived as being irrelevant. Nurses can feel embarrassed about asking certain questions if they feel that the questions are irrelevant or inappropriate—such as questions about sexuality (Mason 1999). In these circumstances, nurses can respond by maintaining a secondary form of ‘real’ working documentation—which directs practice while paying lip-service to the formal NCP framework required by regulatory authorities. For these reasons, it is not surprising that Mason (1999, p. 380) observed:
There is strong evidence that care plans are viewed negatively by nurses and poorly implemented, with little evidence to suggest that they have any positive effect on quality of care or patient outcomes.

communication and a guide to practice’ (Mason 1999. documentation is likely to ‘Nurses frequently complain that they have time to care or time to write— be ignored or inadequately but do not have time for both. • Documentation can be perceived primarily as an administrative requirement that takes up valuable time that might have been otherwise spent on resident care.27 Clinical Reasoning Theoretical plans and clinical experience Conflicts can arise between theoretical plans and clinical experience. and care plans are used to assist in ‘explanation.’ completed if it does not achieve what nurses see as valid goals. . These include the following. p. patients are consulted about proposed care. if nurses believe in the NCP framework and the purposes of documentation. they will pay it more than lip-service. • The theoretical nursing model framework that is in use can be perceived as being irrelevant. • Experienced nurses can consider that the care given in accordance with written nursing plans is of lesser quality than that provided by an experienced nurse who follows his or her clinical reasoning. • It is difficult to write an NCP that is appropriate to all members of the nursing team. However. In these circumstances. In these circumstances. • Nurses can feel constrained to follow nursing plans—even though autonomous thinking and practice would actually be in the better interests of patients. However. nurses’ attitudes to documentation are generally positive. 384). nurses frequently complain that they have time to care or time to write—but do not have time for both. Differing expectations Most regulatory bodies require prescribed record-keeping because they believe that documentation is an essential component of safe professional practice.

’ standards are being met. . and • kept to a minimum (to avoid repetitious and redundant entries). These requirements are pragmatic and political.28 Nursing Documentation Nurses document to meet: • the clinical requirements of those in their care. • innovative and imaginative (to catch the attention and maintain the interest of nursing staff who use it). effective documentation should be (Mason 1999): • descriptive of practice-in-use (without neglecting legal or regulatory requirements). and they must be accountable for the effective spending of that money. • ‘owned’ by the staff members who write and use it. However. Like it or not. documentation is used as evidence that rational thinking and planning are being used in aged-care nursing. Organisational and legislative compliance is directed ‘Like it or not. nurses might not respect the second if organisational documentation frameworks do not adequately reflect the clinical reasoning processes of nurses. and to justify funding for nursing care. In monitoring standards. The two needs co-exist. funding is an essential ingredient in the provision of residential aged care. Effective documentation To work for all involved. • integrated with practice and evaluated throughout the day (rather than being an ‘add on’ that is done before or after the event). and • the requirements of organisational and regulatory compliance. Appropriate standards of aged care must be established and monitored to confirm that professional standards are being maintained. • flexible and tailored to the needs of the clinical area in which it is used. Nurses are a major expense in the aged-care budget. funding is an towards funding requirements and essential ingredient in the providing evidence that established provision of residential aged care.

• Nurses must recognise that documentation is a critical factor in the monitoring of quality and the meeting of funding requirements. Those responsible for documentation must therefore know the residents about whom they are writing. nurses must appreciate that the capacity to ‘The capacity to think through the think through the implications implications of nursing documentation of nursing decisions and nursing is an important factor in establishing professional recognition. and must be aware of the contemporary practices best suited to their needs. • Nurses must ‘bring documentation to life’ by making it relevant and useful to colleagues who are expected to understand it and follow its directions. and management should encourage innovation in the development of practice-focused documentation (Mason 1999). • It should effectively link individually assessed resident needs with contemporary best practice in aged care to achieve the best possible outcomes for residents. nurses should ‘re-invent’ documentation that does not work for them. Documentation that adequately meets the requirements of the resident needs and the direction of nursing care must also be capable of meeting the requirements of policy and regulatory compliance. rather than rely on routine and direction. but the administrative needs of the regulatory authorities must be respected. .29 Clinical Reasoning In addition. However. However. In this context. Conclusion Nurses rely on their own experiences and on organisational and legislative demands to guide and inform the documentation of nursing practice (Brosnahan & Tracy 2002). The clinical needs of individuals should shape nursing documentation. regulatory compliance must not be ignored.’ documentation is an important factor in establishing recognition of their professional status. documentation should meet the following criteria.

Finally. and • be recognised as a critical factor in the monitoring of quality and the meeting of funding requirements. For their part. clinical and educational forums must be facilitated to enable the complementary roles of clinical reasoning and regulatory documentation to be discussed and implemented.30 Nursing Documentation Criteria for effective documentation Effective documentation should meet the following criteria: • link individually assessed resident needs with contemporary best practice. residential aged-care facilities must consider documentation models that promote clinical reasoning by nurses. nurses must evaluate the format and purpose of documentation to ensure that the needs of both the regulatory bodies and those of residents and staff are being met. . To meet the criteria of effective documentation. • be relevant and useful to colleagues who are expected to understand it and follow its directions.

In documenting aged care. Introduction . • education—including more effective ways of documenting nursing care. • communication among members of the healthcare team.’ this. • the requirements of the funding system—by establishing links between the level of nursing care that is provided and the financial reimbursement provided. Documentation in aged care serves many functions beyond a simple account of the day’s nursing ‘Effective communication in aged-care activities—and the level of professional communication nursing demands a level of articulation that goes well beyond ‘telling stories’ in documentation must reflect about what has occurred.Chapter 3 Professional Communication Christine Crofton and Gaye Witney Effective written and verbal communication in aged-care nursing demands a level of articulation that goes well beyond ‘telling stories’ about what has occurred in the care of a particular resident on a particular day. nurses are communicating information that affects the following important matters: • the identification and assessment of nursing-care needs.

and analysis to enable nurses can serve as a powerful to communicate more effectively about problem-solving tool. All nurses subscribe to a code of ethics on entering the profession. Contemporary aged care thus requires a more rigorous approach to professional communication in documentation than has been required in the past. documentation must use feedback. analytical communication system. Communication within organisations Codes of ethics and practice Codes of ethics and professional practice support the contention that communication in nursing documentation should be of the highest standard. a different set of ‘stories’ begins to appear in the documentation—stories that reflect a proactive approach to health needs and nursing care. To achieve this. and • legal requirements—especially protection of staff and the residents in their care. documentation reflection. Organisations must consider how the process of documentation forms part of overall organisational processes. A systematic model of documentation encourages a participative and collaborative approach linked to the development of a ‘learning culture’ in aged-care facilities (Senge et al. It must be recognised that documentation today is an essential aspect of a healthcare organisation’s comprehensive.32 Nursing Documentation • research—by establishing trends in aged-care needs. and nurses who understand and value the ethics of the nursing profession will Codes of ethics . rather than a narrative of reactive responses to what has happened. 1994). • auditing—to validate standards of nursing care. documentation can serve as a powerful problem-solving tool. Properly done. If a systematic approach is instituted. ‘Properly done.’ the many complex issues that arise in relation to nursing care.

If nurses are to maintain their professional standing within these teams. To be professional communicators in the context of nursing documentation. and trustworthy when attending to their documentation responsibilities. reliable. To ensure that the highest ethics of nursing are reflected in their professional communication. it is important that the highest nursing competencies be reflected in the quality of their documentation. not merely the entry that they are making in the notes on any given day. nurses need to: • be skilled in documenting nursing care. • be genuinely supportive of the organisation’s documentation processes and work with integrity within the organisation’s processes for improvement in the system. • know who they are working with. and for whom. the documentation of nurses should be: • factual. (continued) . • accurate. Codes of professional practice Codes of professional practice remind nurses that they are part of a professional team. • current. and • organised. within the aged-care facility. nurses need to attend to their professional responsibilities as outlined in the Box below. • be dependable.33 Professional Communication recognise their responsibility to utilise the documentation system as an integral part of the role of the nurse in aged care. • be an advocate—by putting the interests of the resident first when recording their notations. • be holistic—by looking at the whole documentation system. Professional responsibilities in documentation To be professional communicators in the context of nursing documentation.

and the value of documenting ‘Documentation forms part of a professionally is that it brings comprehensive communication system the separate components of within aged-care facilities. One aspect of the documentation system cannot exist without the other parts. • show initiative when attending to documentation responsibilities.34 Nursing Documentation (continued) • anticipate documentation requirements (rather than waiting to be told what to do). and • accept constructive criticism regarding gaps in knowledge.’ care together. skills. • be a team player by leading and supporting colleagues as they attend to their documentation responsibilities. • actively seek personal and professional responsibility in undertaking a role in documentation processes. ADAPTED FROM MASTERS (2003) Establishing professional communication Holistic perspective As noted above (page 32). documentation is an integral part of the overall functioning of aged-care facilities. and documentation thus forms part of a comprehensive communication system within such facilities. • be observant and honest when recording nursing care. or attitudes with respect to documentation. rather than merely completing the minimum requirements of assigned tasks. • be loyal and respectful towards the organisation’s leaders and documentation processes. . • actively listen when being advised of the requirements of the facility in terms of documentation. • accord documentation a high priority and ensure that documentation is completed properly and promptly. • become involved in documentation processes and opportunities for improvement.

They need to monitor the day-to-day processes of the system itself.35 Professional Communication An obsession with funding requirements and how they impact on the quality and quantity of documentation can distort a holistic understanding of documentation as an integral part of the nursing care delivered to residents in aged care. If the organisation adopts an holistic approach to the documentation process. . committed nurse managers will find that they need to add a new dimension to their management practice. as well as the patterns of behaviour and mindsets of the nurses as they use the system. nurse managers have to develop new managerial skills. Once established. If the inter-relatedness of the various parts of the documentation process is continuously promoted. Eventually they will even claim it as their own. and sabotage it. nurses will be encouraged to collaborate with each other in implementing a comprehensive system of professional communication. At first there might be some resistance to the new system among nurses. ‘At first there might be some resistance and some might even actively to the new system among nurses. Some will be reluctant to use the system. nurses will gradually accept this and come to see that the new system is more effective. once a some might even actively sabotage it. Overcoming resistance The establishment of a systematic approach to documentation requires planning and consultation—from when a resident enters the facility to when that person leaves. However. the effectiveness of the system must be continually monitored to ensure that it is producing the required standard of documentation.’ more efficient and effective process is established. Managerial skills In overseeing the introduction of an effective documentation process. Some will be reluctant to use the system. Two suggested strategies are described in the Box on page 36.

nurse managers should ask themselves whether the problem is: • an issue related to a particular process within the system? • an issue related to the implementation of the system as a whole? • an issue related to nurses’ attitudes to documentation in general? • an issue related to nurses’ attitudes to the new system in particular? Having identified the exact nature of the issue. Two strategies that nurse managers will find helpful are described in this Box. Identifying the issue In analysing any given issue with the documentation process. (continued) . as a unit manager. contributed to this issue? • How would other unit managers see this issue? • What is preventing me dealing with this issue? • What are the consequences of not dealing with the issue? This approach allows the nurse manager to analyse the issue dispassionately and logically—thus enabling problems to be tackled more effectively.36 Nursing Documentation Two strategies for nurse managers The introduction of a new documentation system puts increased demands on nurse managers. Why did the nurse become distracted? Answer: The nurse was working on a shift that was short of staff today and the nurse was trying to fill too many gaps. For example: 1. Asking ‘Why?’ Another strategy that might be useful for nurse managers in assessing issues with a new documentation system is to ask a series of ‘Why?’ questions. 2. Why was this assessment not analysed? Answer: The nurse responsible became distracted and did not complete the requirements. the nurse manager can then address the following questions: • Why is this an issue? • Have I.

This approach allows an analysis of a situation that avoids a judgmental assessment of what a particular person did or did not do. Why did that prevent the nurse completing the analysis? Answer: The nurse did not have time and ‘space’ to complete the process. Why was there a shortage of staff? Answer: A colleague called in late and there was no opportunity to organise a replacement. Why was that not possible? Answer: The process was too complicated to manage when other matters become disorganised and rushed. Coaching can be defined as the . The approach concentrates on why a particular process has not been completed—thus reducing the tendency to ascribe blame to individuals. the organisation must also acknowledge that nurses have to deal with the day-to-day reality of apathy and low morale that is so common with respect to documentation.’ professional responsibilities with regard to documentation. Encouraging and coaching nurses Negative perceptions of documentation are common among nurses and this negative attitude can easily become accepted as the ‘norm’. However. 4. nurses are responsible for developing their own perceptions. 5. However.37 Professional Communication (continued) 3. It is important for the organisation to foster the intrinsic desire of those nurses who wish to improve their own documentation capabilities and those of their colleagues. They should be encouraged. rather than seeing the world from a reactive point of view—and ‘Nurses have to deal with the daythere are many nurses who do to-day reality of apathy and low morale that is so common with have a positive perception of their respect to documentation. as professionals. Management should therefore encourage enthusiastic nurses to take on the role of ‘coach’ in the workplace.

’ that simply tells people what they should do. Some avoid the responsibility altogether and others use it as a chance to have a rest. In this sense. ‘who?’. there are those who use the opportunity to learn as much as they can about the ‘Documentation is part of nurses’ documentation system and about professional responsibilities to those the residents as individuals. coaching is ‘helping [others] to learn rather than teaching them’ (Whitmore 2002. ‘when?’. individual nurses have different attitudes to documentation.’ is more likely to be achieved if all staff members value the system as part of their professional responsibilities to those in their care and as an integral part of the care that nurses deliver. However. However. and ‘how?’. in doing so.38 Nursing Documentation ability to ‘ … unlock potential to maximise performance’. A in their care and an integral part of successful documentation system the care that nurses deliver. . p. A positive staff attitude to documentation is more likely to be achieved if nurse managers reflect on their own attitudes to the documentation process and engage in ongoing constructive discussion of the issues. The process of coaching involves the asking of open-ended questions—‘what?’. This encourages nurses to take responsibility for the processes as designed. they should avoid constant carping criticism of the organisation in general and documentation in particular. These questions facilitate creative thinking about the issues—in contrast to the reactive thought response that is ‘Coaching is helping others to likely to be engendered by instruction learn rather than teaching them. 8). ‘where’?. Assessing the system Positive feedback As noted above. or to make suggestions for improvements to the processes. ‘why?’. The aim is to generate a constant awareness among nurses of their own capabilities and those of their colleagues.

• conducting an initial meeting about the process of gap analysis. and this ‘new story’ will gradually be passed around the facility. A follow-up gap analysis can then be planned to measure the success of the plan. at all levels of the organisation. As staff members come to see the transparent advantages of the system. a gap analysis involves the identification of ‘gaps’ (or deficiencies) in the process. knowledge. An action plan is then developed to implement strategies to address the gaps. and • conducting another meeting to report the findings. Feedback loops can be used to create a ‘new story’ about documentation. This involves ongoing analysis and assessment. ‘The approach is that we have This process is called ‘gap a problem—rather than he or she is the problem. As the name suggests.39 Professional Communication In addressing the attitudes of individual nurses. and attitudes. This should be a problem-solving process—rather than a process of attributing blame for any inadequacies in the system.’ analysis’. • implementing the gap analysis itself—identifying the deficiencies in the documentation process. past practices will be forgotten and the new practices will become accepted as the ‘norm’. and as they become accustomed to a more streamlined system. • preparing a report—based on the evidence collected in the survey. . The process then starts again. patterns of belief can be assessed and altered by constructive feedback. it is important to keep the process alive and flexible. and it should be part of a quality-auditing process that involves all aspects of the organisation—management. the following steps are required: • planning for the analysis—looking at skills. and any ancillary staff who might be involved in documentation. The approach is that we have a problem— rather than he or she is the problem. In instituting a gap analysis. nursing staff. Gap analysis Once a new documentation system is introduced.

• understanding the role of government in documentation processes. and • education and training to support documentation processes. • expectations of staff performance in relation to documentation. • attendance at educational and training session related to documentation. • current documentation knowledge and skills levels of nursing and ancillary staff involved in documentation. skills. . and • willingness of high-achievers with exemplary knowledge. • expectations of performance of nursing and ancillary staff in relation to documentation. • evaluation of documentation resources. Gap analysis A gap analysis should include consideration of such matters as: Management level • the goals of the documentation process within the organisation. Nursing level • the goals of nursing staff in relation to documentation. or attitude towards the documentation process to be promoted as team leaders.40 Nursing Documentation The Box below lists some of the matters that should be examined in any gap analysis. • utilisation of support resources. • roles and responsibilities of all staff in relation to documentation. • understanding of government requirements. • the role and responsibilities of nurse managers in relation to documentation. and • literacy. Ancillary staff • understanding of documentation policies and procedures. • documentation policies and procedures. • utilisation of principles of effective documentation.

this is balanced by the fact that nurses are given space to learn from experience.41 Professional Communication It is essential to evaluate the impact of a new system on nurses and to understand the processes on which they rely to guide them. Such an organisation has a tyrannical attitude in enforcing the rules of documentation. . However. The role of risk management Any new system should be subjected to a risk-management analysis. and develop their judgment. The Box on page 42 contains some strategies to encourage sensible risk-taking in implementing a comprehensive professional documentation system.’ nurses will not feel threatened by a new system. a positive riskhave confidence in approaching assessment process means that this important task. an organisation that adopts an ‘An attitude of risk management attitude of risk management encourages nurses to use their encourages nurses to use their clinical judgment. Gap analysis provides such a systematic analysis.’ clinical judgment. Indeed. Performance improvement must be approached systematically if it is to improve productivity and competence. risk management is a key process in the encouragement of experimentation and creativity. In contrast. trust their intuition. An organisation that adopts a negative attitude of risk control tries to prevent nurses from ever making mistakes. Although risk management is ‘The identification of risk factors sometimes seen as a negative and in meeting responsibilities with documentation enables nurses to defensive process. there is always a risk of not getting it right all the time. In such an organisation. The identification of risk factors in meeting responsibilities with documentation enables nurses to have confidence in approaching this important task.

They do so with an earnest desire to meet the demands of often complex requirements—even if they have little faith in the systems with which they are forced to work. • encourage experimentation and creativity. meaningful tasks enhance professional pride in the nursing role. • encourage nurses to rely on a balance of informed factual analysis and intuitive awareness. The most effective aged-care facilities encourage nurses to learn and grow by offering challenging (and often difficult) work through the documentation system.’ of the system and a strong sense of being involved. . nurse managers are encouraged to adopt the following strategies: • design a formal framework for evaluating risk to ensure that the process is transparent and known to all nurses in the facility. Even if the work is risky. and • encourage an environment in which nurses feel free to discuss ideas and gather resources to assist their own decision-making and that of others (rather than formalising everything and forcing staff to seek approval for any innovation). ADAPTED FROM BENNETT & MATHESON (2002) Conclusion Most nurses who are involved with documentation in aged care work positively to discharge their responsibilities.42 Nursing Documentation Strategies for positive risk-taking To encourage sensible and positive risk-taking. • analyse mistakes rather than punishing them. avoid discouragement unless repeated mistakes are made through a lack of insight and an unwillingness to learn from them. The implementation of a comprehensive documentation ‘A comprehensive documentation system that enhances professional system enhances professional communication provides such communication and provides nurses with a sense of ownership nurses with a sense of ownership of the system.

. and successful organisations often celebrate outstanding achievement—such as coming unscathed through a government audit of the facility’s documentation processes. a well-functioning facility shares a culture of trust in which nurses feel confident to divulge their uncertainties about their ability to meet the requirements of documentation. an effective organisation: • researches what is required and how best to go about meeting those requirements. This requires leadership in which all nurses are held accountable for their documentation practices and encouraged in their efforts to improve. In the ‘In the final analysis. • resolves external and internal obstacles to professional documentation. and • accepts new ideas and expands upon suggestions for improvements in the documentation system. • makes a careful assessment of what should be documented and how to go about documenting it. documentation final analysis.43 Professional Communication Along with risk comes reward. • responds positively to changing requirements. A comprehensive documentation system should be seen as an exercise in professional communication—rather than as a chore to be carried out in accordance with regulatory requirements. Although there is often a healthy and constructive conflict of ideas about how to meet the requirements of documentation. In implementing a documentation system that encourages professional communication among all stakeholders.’ ethical responsibilities of nurses and their codes of professional practice. documentation is a professional responsibility is a professional responsibility in accordance with the ethical responsibilities of nurses and their that is in accordance with the codes of professional practice.


. and documented. They will need to determine what should be done for residents (given current knowledge and national standards). national policy and funding criteria will influence how nursing care is categorised. and how it is planned and implemented. but they have not always achieved their intended purpose. This individualised nursing care. The purpose of NCPs is to provide individualised nursing care. This is partly because they have been standardised and simplified.’ of NCPs and care pathways that emphasise a person’s individual needs. In the future. but they have not always achieved is likely to involve a combination their intended purpose. Nurses and their professional organisations will need to think strategically about nursing care.Chapter 4 Nursing Care Plans Shirley Schulz-Robinson Introduction This chapter discusses the use of nursing-care plans (NCPs) in residential aged-care facilities. rather than what is currently being done. New systems of ‘The purpose of NCPs is to provide documentation will evolve. provided.

injury risk. and who should provide care. This became rules. Roy 1987. chemistry) (Orem 1971. urgency of care. and nursing. McCoppin & Gardner 1994). and traditions (Grant 1979. (iii) interpretation of observations. incontinence. philosophy) and the biological sciences (anatomy. (ii) formulation of nursing problems. and (v) care. The purpose of such NCPs was to promote the provision of individualised care. During the 1980s. powerlessness. various types of cancer. rituals. and anxiety) were used to structure NCPs for people with various conditions—including Alzheimer’s disease. behavioural. nursing diagnosis was developed. . Buckwalter & Maas 2002). This was a classification system developed by the North America Nursing Diagnosis Association (NANDA) (Lewis. Saunders 1999). and traditions. Caplan 1964). Buckwalter & Meriden 2002. depression. These involved five steps: (i) assessment. and social needs of those in their care (Daly. rather than care based on evaluation of care. altered thought processes. sociology. environment. immobility. helplessness. Heitkemper & Dirksen 2000). Such textbook NCPs were useful because they identified actual and potential problems and needs for persons with specific conditions. Roper.’ known as ‘the nursing process’ (Meleis 1997. illness. Parkinson’s disease. Selected diagnoses (such as self-care deficit. Yura & Walsh 1967). Computerised and standardised plans also offered prompts (Daley. physiology. Students were required to develop NCPs to identify care requirements.46 Nursing Documentation Individualising nursing care Since the 1930s. teachers of nursing have used NCPs to assist students in critical analysis and systematic assessment of the physical. Neuman and Young 1972. rather than care that was based on rules. psychological. and anxiety (Lewis. Heitkemper & Dirksen 2000). Logan & Tierney 1996. These models and frameworks drew upon the social sciences (psychology. ‘The purpose of such NCPs was the provision of individualised (iv) development of NCPs. rituals. physics. Grant 1979. By the 1970s students were required to apply models and frameworks—which reflected different views of health.

they could be reviewed for clinical audits. This practice allowed nurses ‘Verbal communication reduced to do things ‘their way’ if they the visibility of nurses’ work. Nurses have shared their observations and judgments verbally with their peers at ‘hand-over’. However. and medical practices of caring for residents. and it worked well if all their provision of individualised care. NCPs allowed nursing care to be isolated and costed. It became possible to judge whether competent nursing assessments had been made. policies.’ historical record. their employers. and the recipients of nursing care (Grant 1979). and their provision of individualised care.’ nurses knew the idiosyncracies of the rules. and whether appropriate care had been provided. Continuity of care was rarely achieved because the system allowed for variability of care if nurses felt it appropriate—and residents suffered as a result. their accountability for what they did. an historical record … the professional accountability and Because NCPs provided an visibility of nurses increased. the reliance of nurses on verbal communication had negative professional consequences because it reduced the visibility of their work.47 Nursing Care Plans Historically. and were able to staff units accordingly. qualityimprovement activities. Benefits and problems of NCPs Benefits By focusing attention on nursing care. NCPs have benefited nurses. and 1999). rather than being a means for nurses to monitor the effectiveness of the care they provide (Schulz-Robinson 1997). routines. Continuity of care became achievable—even if ‘Because NCPs provided numerous nurses provided care. The professional accountability and visibility of nurses had increased. nursing notes have acted as an aide-mémoire for doctors. . and accreditation. Managers were able to calculate the hours of care required for residents’ needs to be met. their thought it appropriate (Wicks accountability for what they did.

because nurses are still required to record data (such as temperature. Grant 1979). documentation is now an integral part of nursing. many facilities have adopted standardised NCPs. the views of patients are given prominence. little time has been saved—especially when nurses are also required to develop and maintain NCPs for their own use. and outcomes that meet residents’ needs. cognitive or emotional state. It fulfils professional and legal responsibilities.48 Nursing Documentation For these reasons. To save time and to promote consistency of information. activities and interventions are planned and evaluated from subjective and objective perspectives. and ‘SOAPIE’ system—subjective. One of individuals—who they are. the best strategies for assisting them. their status. interventions. Some nurses complain that much of this work is unnecessary and that it reduces the time they have available . Because the method allows subjective evaluation. their the easiest care plans is the specific conditions and problems. Documentation still consumes a large proportion (15–50%) of nurses’ time (Daly. Nurses require knowledge about individuals—who they are. and evaluation. their specific conditions and problems.’ objective. assessment. and the care provided. and described from the perspective of the patient (subjective) and the nurse (objective). implementation. However. fluid balance. It can be difficult to identify goals. nurses can sometimes experience difficulties in writing care plans (Coker 1998. functional independence. Grant 1979). and the best strategies ‘Nurses require knowledge about for assisting them. However. The ‘problem intervention’ statements provide an up-to-date overview of problems. Buckwalter & Maas 2002. medication. Problems NCPs take time and effort to develop. planning. Similarly. conveys information about the care provided. and communicates information relevant to the system as a whole (Axford 1995). problems are listed and numbered. Following assessment. elimination patterns. as well as recording the same data in file notes. and food intake) on forms that are later included in files.

These stories should relate what these people wanted to achieve. . rather than relying on the completion of a predetermined proforma. Standardising and streamlining NCPs have reduced their relevance. Reliance on predetermined questions that are answered by ticking boxes (‘yes’. Long-term care poses a challenge for nurses who must identify needs in ways that are meaningful to staff members from various educational backgrounds. ‘Comprehensive documentation is comprehensive documentation is essential if individualised care essential if individualised care is is to be provided.49 Nursing Care Plans for providing care. Nurses are left with insufficient information for planning ongoing individualised care (Coker 1998). The Box on page 50 provides an example of an NCP based on obtaining relevant individual information. If nurses focus on the completion of a prescribed form. where they lived. but nurses must be able to interpret NCPs consistently if they are to provide safe and appropriate care. what they value. It is very difficult for nurses to hold meaningful conversations with residents if their knowledge of those in their care is restricted to their diseases and medications. rather than focusing challenging and time-consuming on the person. their interests. In long-term care. and their hobbies. or ‘not applicable’) limits the quality and quantity of information obtained. However. it is difficult to obtain the information that they require to develop a residentcentred NCP. Writing informative NCPs is difficult and standardised plans do not make it easier. it is difficult to obtain the information that they require. and those that are considered irrelevant. who and what they cherished. remain unasked.’ to be provided. how they earned a living. Discussion is useful. rather than focusing on the person. Personal information is often omitted because openended questions. NCPs are often difficult to understand. NCPs should tell a ‘person story’ (Coker 1998).’ task. ‘no’. Gaining a sense ‘If nurses focus on the completion of a of who the person is can be a prescribed form. and many nurses therefore choose to rely on discussions with peers to gain information. what they did achieve.

Since the death of her husband five years ago. Mrs A gradually began to feel respected and safe. Mrs A had been born in eastern Europe and had emigrated to Australia as a refugee in 1947. her health had deteriorated. and to respond appropriately to her needs. Individualised care can also be impeded by practical considerations— including resident/staff ratios. Heitkemper & Dirksen 2000. As a child she had survived internment in a concentration camp during World War II. Different views of nursing Different views of nursing and the purpose of residential care influence how NCPs are used. Mrs A was withdrawn and fearful. To respond appropriately to this woman’s needs. On her arrival at her ‘new home’. expectations of nurses (Chiarella 2002). Society has various. physical facilities. and fixed routines. and was reluctant to let go of her daughter’s hand. community nursing. as have many professional organisations . Mrs A’s care plan focused on strategies and processes that reduced her fear and helped her to feel safe and in control. and she was therefore afraid of authority. It must be part of the culture of the facility that is enacted in all activities. rigid rules. nurses developed an NCP by obtaining information that assisted nursing staff to empathise with her situation. as responsible practitioners in their own right. government institutions. knowledge levels. skill mix. and mental health. Indeed. As a result.50 Nursing Documentation An NCP based on relevant information Mrs A was admitted unwillingly to residential care because her daughter was ill and unable to care for her. Schulz 1992). and hunger. Nurses can be viewed as ‘doctors’ handmaidens’ and. often conflicting. Resident-centred care must be a stated philosophy of a facility. Many researchers have identified people and their health as the primary focus of nursing (Lewis. simultaneously. the nursing profession itself has not achieved a consensus about the nature of nursing—even in specialty areas of nursing such as aged care. staff mix. Mrs A was illiterate in her own language and her English skills were poor.

and emotional needs of residents in agedcare facilities are similar to the needs of people in the wider community. the needs of ageing people are rarely simple. with service managers still seeing nursing as primarily concerned with illness.51 Nursing Care Plans (including the International Council of Nursing 1994. Other views continue to dominate many practice settings. and medical care. although the care that people require in aged-care facilities is often ‘nontechnical’ or ‘non-medical’.’ nurses are resources for people to use to regain or maintain their health (Schulz 1992). However.’ be done depend on one’s view of what nursing is and what residents need. a resident with arthritis might require assistance . not what is being done. and that working in aged care. Australia in acute general hospitals and 1996). ‘NCPs should state what needs to Decisions about what needs to be done. hospitals. For example. and the ‘Some nurses continue to believe that ‘real nursing’ occurs only Royal College of Nursing. functional. Residents’ needs and the purpose of aged care The medical. Overworked staff—many of whom have modest educational preparation for their roles—are unable to care for all of these complex needs. Some nurses continue to believe that ‘real nursing’ occurs only in acute general hospitals and high-tech facilities. However. not what is being done (Grant 1979). the Canadian Nurses Association 1988. all nurses in residential care have a professional responsibility to ensure that residents are provided with care that meets industry and professional standards. the American Nurses Association 1994. community nursing. Many nurses consider basic personal care to be non-nursing care. This lack of consensus about nursing makes it difficult for nurses to develop effective NCPs—which should state what needs to be done. the World Health Organization 1993. the Royal College of Nursing 1994. This perspective suggests that high-tech facilities. and mental health is not ‘real nursing’.

hostels. • maintaining or improving mobility and independence. Residential facilities are expected to provide aged persons with a safe. For example.’ cope—even with assistance from community services. detachment. People seek residential care for various reasons. Residents require an environment that is physically. withdrawal. loneliness. and urinary reacting to problems as they arise. and nursing homes. An NCP for this person should take account of a range of needs. depression. using the most appropriate care families are no longer able to and contemporary interventions. In Australia. cheerfulness. . and socially safe. using the most appropriate care and contemporary interventions. fear). To recognise changes and identify possible causes. People move to these ‘NCPs should focus on individual facilities when they or their needs. NCPs should focus on these and other individual needs. The Box on page 53 gives an example of how astute nursing awareness can ensure that appropriate care is provided. in general. constipation. Residents can move from one care level to another if necessary. • emotional and social issues (for example. positivity.52 Nursing Documentation when bathing. including: • stiffness and pain. grief. three levels of accommodation are provided—private units. nurses need to know. how elderly persons are likely to react to illness. Care needs tend to fluctuate over time and resident problems vary. • personal hygiene. attending to known needs or falls. and • cultural factors. Care needs must be anticipated by nurses—rather than merely attending to known ‘Care needs must be anticipated needs or reacting to problems by nurses—rather than merely as they arise. home-like environment and ready access to the care and assistance they need.’ tract infections are preventable problems for many residents. emotionally. anxiety.

In recent times Mrs B had become socially withdrawn—with episodes of confusion. They recognised that this woman’s social withdrawal. above) is a good example of astute individualised nursing care that anticipates problems. congestive cardiac failure. and painful rheumatoid arthritis. might develop a ‘silent’ urinary tract infection with none of the usual signs and symptoms (such as dysuria. More specifically.’ subtle gradual changes if they are not reported and properly documented.53 Nursing Care Plans Awareness of other possibilities Mrs B was usually a cheerful and sociable woman of 85 years of age who suffered from limited mobility. It is easy to make assumptions . nurses recognised that a woman of this age. and agitation could be due to an infection. A failure to recognise the possibility of this urinary tract infection might have led to inappropriate treatment. or even admission to a psycho-geriatric unit for investigation. If nurses do not know residents properly. but residential care facilities continue to employ staff whose educational preparation for this work is limited. However. ‘Nurses can fail to identify subtle Nurses can fail to identify gradual changes if they are not reported and properly documented. they must be aware of how the people in their care are likely to react to particular medical problems. but they can also be subtle. or that little can be done apart from providing medication and personal care. Mrs B was investigated for a possible urinary tract infection. and aggression. it is difficult for staff to identify and respond to situations appropriately. At first these signs were interpreted as evidence of early dementia. confusion. The story of Mrs B (Box. Sometimes these changes are dramatic. NCPs can remain unchanged for months if it is assumed that a resident’s condition is static. frequency. or raised temperature). and do not understand that different people respond to specific situations in different ways. especially with limited mobility. if not totally inadequate. The need for nursing care is increasing. agitation. Residents’ needs change. which was subsequently treated with success.

She refused to talk to anyone. and eat her meals.54 Nursing Documentation about people—for example. including the nurses. get out of bed. Sensitive awareness of needs Ms C was a single woman who had been admitted to a residential facility following her mother’s death. . After moving to their ‘new home’. nourishing meals. The nursing staff did not understand what was wrong with her and became annoyed. In contrast. Ms C was admitted because she had a physical impairment that required her to use a wheelchair. assumptions about their ability to understand or make their own decisions—and this can influence how situations are interpreted. A geriatric assessment team had assessed the woman as being unable to care for herself safely. Following a psychiatric consultation. Ms C was admitted to a psychiatric unit for treatment of depression. Many have been previously responsible for the care of others—perhaps a spouse with dementia or another debilitating illness. Several months later Ms C had become withdrawn. as the example in the Box below illustrates. others find that moving into a safe environment—with company. had assessed her with sensitivity and had responded appropriately to her sudden loss of her mother and her home in the space of a few weeks. residents can take time to settle—sometimes weeks or months. she accepted advice that she required respite and rehabilitation. the wellbeing of such former carers can improve dramatically. In effect. Relieved of their burden of care. Eventually. a social worker began to work with her and developed a plan of care that enabled Ms C to return to her home assisted by various community agencies. The unfortunate situation at the residential facility might have been avoided if all the professionals involved with Ms C. and social outings—provides them with a new lease of life. Although she was relatively young (being in her mid 50s). they withdrew from her. They can be depressed on admission or can become increasingly depressed over time. and because she had a mild intellectual disability. Although Ms C was reluctant to be admitted.

and partly because nurses are reluctant to work in an environment in which their work is ‘heavy’ and their wages are lower. aged-care nursing requires more skills. missed problems can often remain unnoticed. Others had informed her that it was a mistake to go into aged care. However. Lost in a backwater? A mature-aged new graduate of nursing was delighted because she had obtained a position in a residential aged-care facility. . When she told me of her success. Aged care was a backwater. Nurses have traditionally believed that a lower level of skill and knowledge is required to work in aged care than in acute care.55 Nursing Care Plans Every person is different—and individuals respond in their own way to what might appear to be similar situations. and that she would be unable to obtain a position in an acute hospital. In these circumstances. Fewer nurses are being employed in residential aged-care facilities— partly because other workers are cheaper. especially observation skills. They had told her that she would be ‘stuck in aged care’. commented on the dynamic nature of aged care today. in long-term care. McCoppin & Gardner 1994). and in which managers do little to attract or retain them (Klitch 2000. This situation is partly attributable to the nursing profession undervaluing the skills needed to work in residential aged care. This was what she had wanted. and spoke of the skills she would gain in her new position. The nursing profession itself undervalues the skills needed to work in residential aged care. problems and needs that are missed by nurses are often noted by other services. In contrast. The Box below describes a situation that is all too common in the profession today. than some areas of acute nursing—in which nurses can rely on support from other professionals and in which the average length of stay is much shorter. I congratulated her. She said that I was the first nurse to respond positively.

and integrity. and • aware of how relevant funding criteria apply.56 Nursing Documentation In general. and preventing (if possible) further problems or illness. • familiar with quality-of-life issues. in which their needs take priority over those of the facility. This does not mean that staff needs should be ignored. Little are met by the employing facility. nurse managers need to provide leadership and set an example. their ability to make their own decisions or initiate activities declined. Nurses are expected to work with people in their care. • knowledgeable about maintaining abilities and rehabilitation. skills. This is now unacceptable.’ social activity was offered and. and nurses are now expected to have the competence. Nursing care can be provided in ways that improve a person’s sense of dignity. residents require nursing care and assistance that is directed at promoting their health and wellbeing. In short. and how best to provide it to meet their needs. and powerlessness—leading to a dependence on those who provide care and assistance. In achieving this. In the past. they became institutionalised. residents were protected from themselves while their medical conditions were ‘ … a working environment in which residents’ needs are met by treated. it means that managers are responsible for providing a working environment in which residents’ needs are met by nurses and in which nurses’ needs are met by the employing facility (Klitch 2000). Rather. shame. But it can also be provided in ways that create anxiety. Regardless of their situation. knowledge. residents of aged-care facilities require ongoing assessment by nurses who are: • competent in using multiple assessment tools. Residents require an environment that is resident-centred. and their rights fewer. Their responsibilities were nurses and in which nurses’ needs few. autonomy. • aware of physical and psychological changes associated with ageing. over time. and attitudes to encourage residents to participate in making decisions about the type of care they require. .

and senior staff who provide leadership and create an ‘Skills in documentation. and decision-making. Nurses must be competent in all of these areas if they are to engage in safe practice in consultation with other members of the multidisciplinary care team. These resources include a sufficient number of staff members.’ participation in assessment. rather how they convey information about than recipients. • the formulation of nursing-care plans in consultation with others (taking account of the therapeutic regimens of other members of the healthcare team). rather than recipients (Bonn 1999). . They need to be considered partners in their care. many of whom require explanations to be given simply and slowly because their comprehension is hindered by their circumstances. Documentation skills can help to facilitate: • the recording of relevant information (and communication of it to colleagues). and reviews of plans in accordance with evaluation data. careplanning.57 Nursing Care Plans Nurses who seek to foster a sense of independence and control in residents need to think about the way in which they provide care—how they create opportunities for expression of concerns. Nurses working in aged-care facilities require resources if they are to provide individualised care. are essential environment that fosters resident to collaborative nursing care. and in NCPs in particular.’ problems. • the implementation of planned care. Skills in documentation. ongoing education and training. and ‘Residents need to be considered partners in their care. Effective communication needs time—especially when dealing with elderly people. and • the evaluation of outcomes. fears. and in NCPs in particular. and wishes. Residents need information and explanations about their care and how to improve their health. • comprehensive and accurate nursing assessments. are essential to such collaborative nursing care. an appropriate skill mix.

and there is no reason for such tools not being developed for residents of aged-care facilities.’ that the nursing care of residents is planned and implemented by appropriately skilled personnel. The population of healthcare providers is now more diverse and specialised. it is essential to all those involved in care. readily accessible and meaningful In these circumstances. plans of care are best developed by teams of people who have the appropriate skills and knowledge—guided by care paths that are accepted as effective for achieving certain outcomes. To achieve these outcomes. culturally appropriate. Nursing-care paths are used widely in acute medical and surgical settings. or developing complications. preferences. in conjunction with other professional groups. nursing care was provided according to tradition. have been involved in developing such care paths or ‘critical pathways’. nurses. Plans of care are best developed in consultation with the resident concerned or in consultation with family or friends if the resident is incapable of participating. The benefit of these ‘paths’ is that they enable nurses to identify individuals who ‘drop off’ the track—by recovering more slowly. and medical preference. Such plans must be consistent with best practice. and speech pathologists. Elderly persons often find themselves referred to practitioners other than doctors or nurses—such as social ‘It is essential that nursing care workers. and documented so that it is readily accessible and meaningful to all those involved in care. and individualised to reflect residents’ values.58 Nursing Documentation Nursing-care paths Before NCPs became a standard part of nursing practice. occupational is … documented so that it is therapists. progressing differently. These paths provide staff with a guide to expected progress of specific problems over time. Much has changed. or medical practitioners. . Nursing care was often provided according to the traditional practices of particular institutions. and personal concerns. services. evaluated against set standards. routine. psychologists. In the past decade or so.

whether it takes into account personal preferences (with regard to routines. Apart from these ensure that the contribution of legalistic considerations. but this is easier to achieve if those providing care reach agreement about what they are trying to do. and whether they acted facilitate continuity of care. page 54). • how to identify signs of depression. Such pathways could offer guidance on: • the likely response of such people. Records are used to assess whether nurses acted within the law. interests. and ensure that the contribution of nurses to care is visible (Schulz-Robinson 1997). . provide accountability. provide accountability for clinical decisions. and so on). In the case of Ms C. Nurses should be able to access a care pathway for people such as Ms C who are admitted unwillingly to residential care. Conclusion Comprehensive documentation cannot ensure that quality nursing care is always provided. and whether the individual’s family situation and background are reflected in the care plan. and competently.59 Nursing Care Plans Consider the story of Ms C (Box. Increasingly. nurses are being judged on the basis of their clinical records—judgments are made about what occurred and what should have occurred. it is likely that staff would have been able to identify her depression at an earlier stage and would have recognised it as being due to her grief over the loss of her mother and her home. meals. • awareness that they are not adjusting as expected. judgments nurses to care is visible. whether they complied with professional codes of ‘Improved documentation can practice.’ are increasingly being made as to whether care demonstrates respect for the individual concerned. Improved systems of documentation can facilitate continuity of care. and • how to devise strategies for assisting them to adjust to their new situation.

physical facilities. and ready access to medical staff and other health professionals. In these circumstances.60 Nursing Documentation Poor documentation does not necessarily indicate poor practice. like other professional groups. vulnerable. disability. However. nurses. how it and changing expectations of is provided. and why. and the organisation involved. In addition. and difficult emotional or social circumstances. have an ethical responsibility to write informative NCPs that ensure continuity of appropriate care and that indicate that their actions—based on competent professional assessment of ‘Nurses. The notion of ‘best practice’ or ‘evidence-based practice’ offers a standard against which the quality of nursing care can be judged. continuity of appropriate care. like other professional groups. a resident’s needs—have have an ethical responsibility to achieved the outcomes of write informative NCPs that ensure care desired by the resident. Clinicians can provide the evidence they require. how it is provided. nurses require NCPs that are explicit about the nursing care required. and disabled individuals who have chronic health problems associated with age. To achieve high-quality nursing care. ‘Quality’ is a nebulous term and difficult to define—especially in a nursing context in which its meaning is ‘Nurses require NCPs that are explicit influenced by new knowledge about the nursing care required. nurses are often required to delegate . and why.’ the team of professionals. sufficient qualified personnel. Although financial affairs and budgets are primarily the responsibility of administrative and managerial staff. Planning care is an essential element of nursing practice. aged-care facilities require resources. Planning is especially important in aged-care nursing because nurses are required to care for elderly. If CEOs are to obtain increases in funds— to employ more qualified staff or to acquire essential equipment—they must have evidence of need. the documentation standards of clinical nurses has a vital role to play in budgetary allocations.’ society and governments.

In these circumstances. and education varies.61 Nursing Care Plans important aspects of this care to other persons—whose experience. commitment. . accurate and effective documentation of nursing-care plans becomes indispensible.


and to inform others of any significant events. It is important for (RDNS 2000): • assessment. and each nurse is responsible for practising in accordance with these policies. . Purposes of documentation Documentation is a very important component of professional nursing practice. each healthcare organisation has policies about recording and reporting resident care. In addition to legal and funding requirements. It must always be remembered that a resident’s notes represent a permanent written record of that person’s nursing care and management. • communication. Nursing documentation in the aged-care sector is also a record of aged-care standards and accountability. As such.Chapter 5 Progress Notes Joanne Hope and Pamela Bell Introduction Effective communication in aged care is vital to the quality of resident care. Documentation is used to communicate details of the nursing care provided. documentation provides a link between funding and professional responsibility for resident-centred care.

Continuity of care Effective documentation allows ongoing nursing care to be delivered by any nurse—and ensures that the effects of that care are known by all. continuous quality improvement (CQI). Progress notes act as a measure of the nursing needs and personal-care needs of residents. Education Documentation allows nurses to read a history of past events. Continuous quality improvement Standards are maintained through continuous quality improvement (CQI) practices. and treatments relevant to the person in their care. Legal requirements Accurately reported facts are the best defence against litigation. Reimbursement Documentation assists aged-care facilities to receive reimbursement from government agencies.64 Nursing Documentation • • • • • continuity of care. Many organisations have audit schedules and use audit tools to ensure that these standards are being met. Purposes of documentation The purposes of documentation can be briefly summarised as follows.All residents have a legal right to safe. Each of these is briefly discussed in the Box below. and reimbursement. thus allowing resident dependency to be assessed. Communication Effective record-keeping improves communication among nurses. programs. . education. professional nursing care—including accurate and truthful documentation. legal requirements. Assessment Nurses directly involved with the nursing care of a resident can use the documentation as a primary source of assessment data.

• not leave space after or within the entry. The Box below summarises some important principles to follow in all forms of documentation. and ensure follow up. nurses need to pay attention to certain principles. Quality aged care requires quality information. • check previous entries. and • never document in pencil—nurses should always document in a black or blue pen. Principles of documentation The following principles should be applied to all forms of documentation. entries should be printed. • be accurate and factual—what was done and what was seen. • be concise—quality not quantity. • never erase an error or use ‘white out’.65 Progress Notes Principles of effective documentation Accurate documentation is a high priority in the provision of quality aged care. These principles should be applied to writing reports. and recording progress entries. rather. • be conscious of correct grammar and spelling. and if this is to be provided. • make entries legible—if handwriting is not easy to read. Nurses should: • ensure that the entry is made in the correct chart. • use simple language that staff understand—nurses should not use jargon and should use only accepted abbreviations. nurses should sign it close to where the entry has finished. initial the correction. • sign all entries and write their designation—print name if signature is not legible. completing clinical record forms. nurses should put a line through the error. . • indicate the date and time in the left-hand margin at the beginning of each entry. and continue with the entry. writing-up plans of care.

Residents’ clinical files should be available only to authorised personnel. nurses usually follow a ‘charting-by-exception’ model (see below. This file is kept in a locked cabinet at the nurses’ station or in a locked room. that nurse is responsible for the update and maintenance of all residents’ records. the senior carer is responsible for overseeing residents’ records and ensuring that they communicate the current status of residents and promote continuity of care. If a registered nurse is employed to care for residents in an agedcare facility. They enable relevant personnel to become aware of each other’s observations and actions. Progress notes thus offer a record of continuity of care. and • legal or professional best practice. Responsibility for progress notes Frequency and quality of entries The frequency of documentation is dependent on: • the policy of the organisation collecting the data. and present a record of the needs. There is often an expectation that all nursing staff contribute to a resident’s progress notes. All other health professionals attending to the resident are also required to make a professional notation in the progress notes at each visit. page 70). Progress notes act as a point of reference to inform others of any significant events or developments relating to a resident. These notes are commenced on the day of the resident’s admission and cease on the day of discharge. The nature of progress notes Progress notes are located in a designated section of a resident’s clinical records file.’ is employed. In facilities in which no registered nurse ‘Residents’ clinical files should be available only to authorised personnel.66 Nursing Documentation Progress notes (or ‘ongoing notes’) function as an ongoing communication record in a shared-care situation. Depending on organisational philosophy. . behaviours. and responses of residents to nursing care.

this ensures that the progress notes at any given time function as an accurate record of nursing care given to date. If progress entries are made at the time of the incident or observation. but with no positive outcomes. Progress notes must be written with reference to. and a minimum of one entry per week for a resident with low care needs. that they comply with the policies of the facility’s documentation system. nurses must ensure that all entries are chronological and timely. Historically. subsequent entries might show the same complaint followed by similar interventions. it is necessary to document more frequently. maintenance of professional and ethical standards. Sequential entries of developments must be made throughout the shift. It is recommended that progress notes are always maintained chronologically—from the oldest to the newest. Changes to the nursing-care plan must be referred to in the progress notes.67 Progress Notes Most facilities follow a ‘charting-by-exception’ policy. and in conjunction with. it is essential that the followup nursing actions are recorded in the progress notes—for reasons of continuity of nursing care. The nurse is responsible for the coordination of resident care and documentation. and legal accountability. with a resident’s level of care needs determining the frequency of entries. and that they fulfil legal requirements. In this situation. If a resident’s care needs increase. this has not been standard practice and progress notes have . However. All changes in nursing care needs must be reflected in the nursing-care plan. the resident’s nursing-care plan at the time of each entry.’ of documentation is ultimately a professional judgment. ‘Nurses must ensure that all entries Although the frequency are chronological and timely. For example. A critical part of this role is to ensure that there is follow up of previously identified nursing-care needs. All entries should be made in the progress notes as close as possible to the event or observation being noted. a notation in the progress notes might refer to a resident complaining of a headache and might note appropriate interventions taken by the nurse and positive outcomes following those interventions. A facility might require a minimum of one entry per day for a resident of high care needs.

The omission of ‘Accurate documentation is a high data has potential legal implications priority. aside to attend to this important Progress notes are made by aspect of quality aged care. This is unsafe practice because it relies on the nurse’s memory and can be affected by fatigue and time pressures. • charting by exception. Progress notes are therefore: • a sequential record of the resident’s care. and • part of a pattern of documentation central to all other documents in a residential aged-care facility. • narrative progress notes. and nurses are responsible for ensuring that information pertinent to the resident is professionally documented and communicated. Each of these is discussed below. • a reference point of updated information for other members of the healthcare team (promoting continuity of care). It should be remembered that accurate documentation is a high priority. and • integrated progress notes. the notes are arranged according to a resident’s problems or concerns—rather than according to the source of .68 Nursing Documentation traditionally been recorded at the end of a shift. • focus charting. Common methods of documenting progress notes Common methods of documenting progress notes include: • problem-oriented documentation.’ all health professionals involved in a resident’s care. and nurses must set time relating to duty of care. Problem-oriented documentation In a problem-oriented record. and nurses must set time aside to attend to this important aspect of quality aged care.

• assessment.1 The SOAP charting method ADAPTED FROM RICHMOND 1997. includes measurements (vital signs) as well as observable behaviour Interpretation of the subjective and objective data A plan of nursing care. 107. Over time. The SOAP charting method is described in Table 5.2 Additions to the SOAP charting method ADAPTED FROM RICHMOND 1997. action (or planned action) based on the assessment. P. PUBLISHED WITH PERMISSION Category Education Referral Description Information and education provided to the resident and to the resident’s family Referrals to other disciplines. The letters of the acronym stand for: • subjective data. and • planning. Plans for each active or potential problem are developed.1 below. Table 5. ‘SOAP’ is a charting method devised for use with problem-oriented health records. Problem-oriented records alert everyone to the resident’s needs and make it easier to track the status of actual or potential problems arising from those needs. the SOAP format has been modified to include ‘education’ and ‘referral’. and progress notes are recorded for each problem. as shown in Table 5. or programs .2 below. includes residents’ emotional responses Observations made of residents by members of the health team. includes evaluation of nursing care Assessment Planning Table 5. • objective data. 107. P. PUBLISHED WITH PERMISSION SOAP category Subjective data Objective data Description What residents say and how they say it. services.69 Progress Notes information.

a sign or symptom. The focus might be a change in the resident’s behaviour or health status. The data include all information relevant to the current focus— including observation of resident status and behaviours. . The acronym DAR stands for: • data. This means that the only nursing care documented in the progress notes is care that differs from that recorded in the nursing-care plan. and • integrated progress notes. and any relevant data from flowsheets (for example.70 Nursing Documentation Common methods of documenting progress notes This section of the text discusses the following common methods of documenting progress notes: • problem-oriented documentation. focus charting concentrates on a specific area of a resident’s experience. Action includes all nursing interventions. Focus charting As the term suggests. Charting by exception Charting by exception (CBE) is a charting system in which only significant findings or exceptions are recorded. The progress notes are organised into three components— collectively referred to as ‘DAR’. This might also include any changes to the resident’s nursing care plan. Response describes an assessment of the resident’s response to the action. • action. • focus charting. and • response. or a significant event. vital signs and pupil reactivity). • charting by exception. • narrative progress notes.

whereas status during a working shift. Narrative progress notes Narrative progress notes are used most frequently in source-oriented health records. and • opportunities for the nursing-care plan to be updated simultaneously to maintain current interventions. findings. Narrative charting consists of notes that document routine nursing care. • promotion of holistic nursing care—the regular and systematic review of nursing care and ongoing identification of nursing-care needs (which encourages a total view of the resident). descriptive accounts of a resident’s and progress notes. The guidelines presented in Figure 5.’ nurses write separate ‘narrative’ nursing notes. • test results. different members of the healthcare team write in separate sections of the resident’s file— for example. • doctors’ visits.71 Progress Notes CBE has many advantages ‘Charting by exception provides for the residential aged-care nurse more time for individual nursing because it provides more time for care by eliminating unnecessary individual nursing care by eliminating and repetitive charting. .’ unnecessary and repetitive charting. Some examples include: • what nurses did with. and • any variation in medication administration. In such source-oriented health records. and for. history. the residents. Other benefits of CBE include: • provision of an immediate. • accessibility and easy data interpretation in emergencies. Such narrative progress notes are descriptive accounts of a resident’s status during a working shift. accurate picture of the resident.1 (page 72) have been developed to assist nurses when documenting resident care. a physician uses a ‘Narrative progress notes are physician’s order sheet. and resident problems.

PUBLISHED WITH PERMISSION . Maintain the CBE process to keep healthcare team informed. P. YES What nursing action was different from the care detailed in the plan? Why was the care different? Was the change: short term? long term? What was the outcome of that nursing action? Reassess the nursing care Review nursing diagnosis Adjust the individualised care plan Notify healthcare team of adjustments Recommence CBE process Notify others of the changes Figure 5. 40.1 Guidelines for CBE documentation ADAPTED FROM RICHMOND 1997.72 Nursing Documentation Look at the standardised individualised nursing-care plan Was any nursing care delivered this shift that differs from the standardised and individualised care plan? NO There is no need to make an entry in the progress notes this shift.

• They maintain a focus on resident needs. However. Narrative notes and source-oriented records are convenient because they facilitate the tracing of information specific to the nurses’ own professional discipline. • They provide easy access for cross-referencing and sequential event mapping. rather than the documentation being determined by the needs of external funding tools. • They help to identify patterns of nursing-care needs. . • They increase opportunities for continuity of care. This system is preferred to discipline-specific or segregated notes—which are the notations made by each member of a specific health discipline. although it usually follows a chronological order. Integrated progress notes The majority of residential aged-care facilities prefer to keep chronological integrated progress notes. medical practitioners ‘Integrated progress notes maintain often prefer to keep their medical a focus on resident needs. and it can therefore be difficult to find chronological information on a particular resident’s progress. • They facilitate accurate communication between permanent and casual staff.73 Progress Notes There is no right or wrong order to the information. The advantages of integrated notes include the following.’ notes separate from an integrated system of documentation. and decrease the likelihood of fragmentation of resident information. However. the information about a particular resident is sometimes scattered throughout a resident’s file. • They provide a common point of reference for all health professionals to access information relating to current resident-care status.

Managers should ensure that a list of acceptable abbreviations and terminology is available for nurses to consult. Personal information should not become known by persons other than those who are directly involved in the resident’s care. It is also advisable to minimise abbreviations used in progress notes. Abbreviations should not be used unless they have clear and unambiguous meanings. nurses must of care to maintain confidentiality. Avoidance of disciplinary/legal action To avoid events that result in disciplinary and/or legal action. This is more likely to occur if a significant period of time elapses between the provision of the nursing care and the hearing of a subsequent legal case. and can result in malpractice actions. Misinterpretation of an abbreviation can lead to harm being done to residents.’ ensure that informed consent is obtained from the resident before releasing information to any person other than those directly concerned with care. The rights and values of residents must be respected at all times. Subpoenaed notes It should be understood by all nurses that progress notes can be subpoenaed and used as evidence in legal proceedings—even though the author might be absent. comprehensive. nurses have an ethical and legal duty of care to maintain confidentiality.74 Nursing Documentation The disadvantage of integrated notes is that they can cause some inconvenience—because access to shared documents is not always available. documentation must represent the knowledge of the nurse who has . Documentation must therefore be accurate. Ethical and legal implications Confidentiality On a day-to-day basis. and legible. In maintaining ‘Nurses have an ethical and legal duty confidentiality.

and verbal reporting must be followed up with documentation of any incident or concern. It requires secure storage. A report should never be written or signed on behalf of another nurse. and left on a desk or in a public space should therefore be available only without supervision. and all resident records must be kept up to date. and a report should never be altered by someone other than the ‘Documentation must represent original author. The nurse Anything amiss with either the who signs the report vouches for resident or the environment should be its truth and accuracy. Documentation should therefore be attended to punctually and conscientiously. Those that are not immediately required should be culled and archived.’ recorded and reported promptly. When not in use. Because mistakes can be made. The contents of a resident’s ‘A resident’s file should never be file should be confidential. the resident’s file should be secured in a locked cabinet or room. the knowledge of the nurse who has written the report. File management A resident’s file is a document that is handled on a daily basis. . it should also be remembered that resident records can serve as a reference for management in the event of a disciplinary complaint. Old records within the resident’s file should be regularly reviewed for currency. it should be remembered that progress notes are an ongoing legal record of nursing care that can be subpoenaed in a court of law. As noted above (page 74).’ on a restricted basis.75 Progress Notes written the report. The nurse who signs the report vouches for its truth and accuracy. Apart from formal legal proceedings. and a variety of filing systems can be utilised for this purpose. A record of archived documents should be indexed in an archive register. orders should never be transcribed. A resident’s file should never be left on a desk or in a public space without supervision. Records should be held for legislated periods of time.

Responsibility for this should be delegated appropriately. by whom it was copied.76 Nursing Documentation The documents themselves should be stored in a fire-safe environment in a locked room. and the stored information must be secure. prevent unauthorised access. Specific timeframes should be determined by legislation and organisational policy. and disposal of electronic documentation. storage. considerations include clinical matters. Organisations need to ensure that there are documented policies and procedures that address the filing. If a request is made for a record. Electronic documentation The same principles apply to electronic documentation as apply to hardcopy documents. and the intended recipient and destination. there must be mechanisms to effective. nurses should refer to the organisation’s policy on such requests. The system must be efficient and effective. and secure. In principle. When using an electronic information system. a duplicate of all stored information must be maintained. Advice needs to be sought from a legal practitioner before destroying any resident documentation. In deciding how long records will be retained. and an historical ‘trail’ during the resident’s . ‘The same principles apply to To validate entries and to electronic documentation as apply to hardcopy documents … efficient. and research needs. movement. and that a signed record be kept on file of what was copied. the possibility of litigation. residents’ files must never be removed from the premises. They provide an overview of all care delivered. retrieval. ‘Residents’ files must never be Most organisations require that the removed from the premises.’ control access. Conclusion Progress notes are vital documents in resident care.’ relevant section of the resident’s file be copied.

completion of resident records is a basic nursing responsibility. and any other important information relating to a specific resident—including physical. and spiritual aspects of care. progress notes reflect all aspects of nursing care in conjunction with the nursing-care plan. ‘Accurate charting and social.’ Progress notes advise nurses of changes in resident nursing-care plans and clinical assessments. actions taken. In summary. This gives nursing and medical staff the current clinical data they require to make appropriate clinical decisions. Accurate charting and completion of resident records—including progress notes—is a basic nursing responsibility. Progress notes function as an ongoing diary of events. psychological.77 Progress Notes stay in the aged-care facility. emotional. .


Choong et al. increasingly sophisticated interventions and services. and Angela Crombie Introduction Healthcare costs in the Western world have increased significantly in recent years as a result of advances in technology. 2000). Dowsey et al.Chapter 6 Clinical Pathways Jenni Ham. Ann-Maree Conners. and this has prompted nurses to examine their practice with a view to ensuring that the expectations of the community are met in terms of safe and effective service provision. 1999. and the need for highly trained health professionals. There has also been an increase in consumer interest and participation in health care. many acute and subacute healthcare organisations have introduced evidence-based clinical pathways (Frink & Strassner 1996. . Ham 2001. The aim of such clinical pathways is to achieve quality outcomes within a specified timeframe. This has meant that health services are continually examining ways to reduce costs—without compromising the quality and effectiveness of the nursing care they provide. using the resources that best meet patients’ needs. ageing populations. In response to these demands for cost reductions in an environment of increased consumer interest in health care.

80 Nursing Documentation In response to the challenges of the modern world. case type. These terms include: • best practice. • resident pathway. • guidelines. Each of these terms is discussed below. Clinical pathway A clinical pathway is a best-practice tool used to organise and integrate all levels of health care delivered by providers from a number of disciplines. • interdisciplinary healthcare teams. . • resident-centred care. and • health outcome. • continuous quality improvement. • evidence-based practice (and evidence-based clinical pathways). Best practice Best practice is a comprehensive. • clinical pathway. Defining terms The terms used in relation to clinical pathways are often misunderstood or confused. or cohort of patients—with a view to achieving desired outcomes in a defined period of time. • variance (and variance analysis). integrated. nurses in a range of healthcare settings are thus showing increasing interest in the value of clinical pathways—and aged-care nursing is no exception. and cooperative approach to the continuous improvement of all areas of healthcare delivery (DVA 2001). It involves the identification and documentation of a sequence of evidencebased interventions for a particular procedure.

Evidencebased practice strengthens the validity of clinical pathways ‘Evidence-based practice strengthens the validity of clinical pathways and and increases the probability increases the probability of achieving of achieving optimal health optimal health outcomes.’ outcomes (Shorten & Wallace 1997). 1993). . residents.’ professional practice in the clinical setting (Ham 1999). thus promoting effective “timelines” of courses of treatment. An evidence-based clinical pathway is one in which the events and activities contained in the pathway are based on evidence. A clinical pathway allows the interdisciplinary healthcare team involved in the treatment of a person to know exactly when treatments and therapies should occur. and family who constitute an interdisciplinary healthcare team share common values and work towards common aims and objectives (Falconer et al. Resident pathway A resident pathway is a concise version of a clinical pathway that is designed for the purpose of resident education and involvement in the planning of nursing care. Information is expressed in lay terms to promote understanding of the nursing-care process and its anticipated outcomes. Interdisciplinary healthcare teams The health professionals. A pathway provides a framework to guide nurses in the provision of ‘Clinical pathways can be simply described as “roadmaps” and care.81 Clinical Pathways Clinical pathways can be more simply described as ‘roadmaps’ and ‘timelines’ of courses of treatment. Evidence-based practice and evidence-based clinical pathways Evidence-based practice is the conduct of health care according to the principle that all interventions need to be based on the best current scientific evidence (Shorten & Wallace 1997).

82 Nursing Documentation Resident-centred care In resident-centred care. Residents (and their families and supporters) are informed of expectations and progress throughout the illness (Hampton 1993.’ results in achievements being less than predicted. Guidelines Guidelines are the principles that set standards and direct the clinician in decisions regarding care. A positive variance results in achievements being greater than predicted. The deviation might alter the resident’s expected outcome or expected length of stay in hospital. Guidelines also form a basis for the evaluation . nursing care focuses on the resident and his or her desired outcomes within an estimated timeframe (which is specified in the clinical pathway). personnel. Variance analysis determines whether predicted outcomes on a clinical pathway have been achieved. Continuous quality improvement in health care involves the ongoing analysis and improvement of all the processes of care—including the hospital system. clinical management. or whether unpredicted events have occurred. Variance and variance analysis A variance is a deviation from the standard events specified on a clinical pathway (Frink & Strassner 1996). Continuous quality improvement Continuous quality improvement focuses on the processes used to achieve desirable outcomes. Zander & McGill 1994). and the financial structure surrounding residents (Cesta 1993). ‘Variance analysis … enables a continuous quality-improvement whereas a negative variance process to be implemented. Variance data are collected and analysed to assess the quality and efficiency of the nursing care delivered—thus enabling a continuous quality-improvement process to be implemented (Frink and Strassner 1996).

The objectives of designing and implementing clinical pathways in aged care are summarised in the Box below. within an estimated timeframe. Objectives of clinical pathways The objectives of designing and implementing clinical pathways in aged care are: • to sequence and coordinate the interventions that are necessary to achieve desired resident outcomes. that can be wholly or partially attributed to a health intervention or a series of interventions. Guidelines reflect best practice and are therefore evidence-based statements.83 Clinical Pathways of various aspects of healthcare delivery. . • to plan resident care in advance and to utilise resources effectively. • to develop a resident-care system that depends on interdisciplinary collaboration and teamwork (including the resident and family as part of the team). • to improve referral and transfer processes. a group of people. or a population. and • to monitor residents’ progress. • to allow residents and their families access to health and lifestyle options. Objectives and results of clinical pathways Clinical pathways are outcome-based tools that aim to maximise the quality of resident care with the resources available. • to base the interventions on the best evidence available. Health outcome A health outcome is a change in the health of an individual. • to implement planned activity of nursing care that enables residents to achieve mutually agreed goals. • to develop a continuous quality-improvement process through variance analysis.

. The improvements that have been reported as a result of the successful implementation of clinical pathways are summarised in the Box below. • timely response to resident problems resulting from frequent analysis of variations from the clinical pathway. DVA 2001). • improved interdisciplinary teamwork with all members of the team being better informed by knowing in advance the plan of nursing care and desired resident outcomes.84 Nursing Documentation Clinical pathways were initially introduced with the aim of reducing the length of stay of patients in acute health settings and reducing the overall costs of hospital care—while maintaining the quality of health care. health-service providers in other settings (such as subacute and community services) have become involved in the design and implementation of clinical pathways for their client groups (Ham 1999. Results of clinical pathways Some of the improvements that have been reported as a result of the successful implementation of clinical pathways include the following: • the delivery of coordinated. resident-centred care with increased involvement by residents and their families in planning nursing care processes and expected outcomes. • implementation of a continuous quality-improvement cycle through analysis of variances. • a greater awareness by the interdisciplinary team of best-practice procedures and resource management. with the implementation of clinical pathways. However. Organisations of varying sizes and heterogeneous client groups have increasingly become involved in clinical pathway design and implementation. below). • documentation being streamlined and duplication being reduced. and • increased staff satisfaction. As a result. many other benefits have been recognised (see Box.

Many acute and subacute healthcare providers have adopted clinical pathways. brought about by the ageing of the population. a variety of skills. plan. and the introduction of such pathways into residential aged care would enhance gerontic nursing as a specialty profession with its own professional tools. • resident-centred and outcome-based care. and evaluate care. clinical pathways offer benefits in terms of: • changing perceptions of aged-care nursing. • streamlined documentation. . Clinical pathways are accepted as professional tools by these clinicians. Changing perceptions of aged-care nursing The traditional ‘palliative culture’ that used to permeate residential aged-care facilities is undergoing significant change. and clinicians in those sectors are required to justify any variance from pathway protocols. and • evidence-based practice and continuous quality improvement. Each of these is discussed below. implement. An increasing need for aged-care facilities. • the functioning of interdisciplinary healthcare teams. is forcing governments and other authorities to reassess the quantity ‘Gerontic nursing has become a specialty area requiring and quality of aged-care services. • staff satisfaction.’ Residents of aged-care facilities have more complex care needs. for which nurses must assess. • assessment and referral. Gerontic nursing has become a specialty area requiring a variety of skills. The introduction of clinical pathways into residential aged care can assist in raising the profile of gerontic nursing by providing the same standards for nursing-care planning and documentation that are required in the acute-care health system.85 Clinical Pathways Clinical pathways in aged care Clinical pathways offer many potential benefits to nurses engaged in residential aged care. In particular.

and to promote collaborative care planning. • assessment and referral. • staff satisfaction. • streamlined documentation. when it is and review individual care required. Each of these is discussed in this section of the text. Evidence-based clinical pathways can help to identify . clinical pathways offer benefits in terms of: • changing perceptions of aged-care nursing. Clinical pathways in aged care Clinical pathways offer many potential benefits to nurses engaged in residential aged care.’ requirements. Clinical pathways provide a framework ‘Clinical pathways ensure that all team members are aware of what for healthcare teams to assess type of care is required. Clinical pathways facilitate communication among members of the healthcare team—thus ensuring that all team members are aware of what type of care is required. teamwork. when it is required. and who will deliver it. there must be collaboration. • resident-centred and outcome-based care. and effective integration of the different disciplines within a healthcare team. Assessment and referral One of the main advantages of implementing clinical pathways in the residential aged-care setting is to guide the nursing team through the assessment process. and who will deliver it.86 Nursing Documentation Interdisciplinary healthcare teams If holistic health care is to be delivered. Interdisciplinary input into the pathway enables a comprehensive biopsychosocial approach to care and management. • the functioning of interdisciplinary healthcare teams. In particular. and • evidence-based practice and continuous quality improvement.

‘Clinical pathways can guide the clinical pathway might assessment and referral. A generic clinical pathway in residential aged care takes the nurse through a comprehensive assessment process—including admission assessment. these might include preventing further impairment in balance. Sharing pathways among service providers prevents duplication of assessment and facilitates transition from one care provider to another as the resident progresses through episodes of care in sequential stages. After assessment has been completed. Clinical pathways can assist in identifying appropriate healthcare team members to provide the required support through relevant referrals. and can provide assessment of mood streamline nursing care by enhancing using a validated tool—such collaboration among service providers. Clinical pathways can thus guide assessment and referral. a clinical pathway incorporating a falls risk-assessment tool might reveal that a resident has balance impairment. Outcomes and goals in this example might include the resolution of symptoms and the prevention of further depressive episodes. or walking a certain distance each day. To take another example. risk assessment. This could trigger referral to a physiotherapist for a more comprehensive balance assessment. and assessment of specific health domains. The GDS score can be used to guide nurses in identifying the presence of depression and in referring the resident to specialist services. In the falls domain. and can streamline nursing care for residents by enhancing collaboration among service providers. planned interventions must reflect the individual resident’s abilities and limitations.’ as the geriatric depression scale (GDS).87 Clinical Pathways assessment domains and can provide guidance on valid and reliable assessment tools. . The pathway should also identify desirable outcomes that reflect the resident’s individual goals. For example. together with a plan of nursing-care interventions required to reduce the risk of the resident falling.

’ outcomes that enhance the quality of life of the individual. The initial assessment provides the foundation for individual goal-setting and a baseline to monitor progress. Many family members are capable and keen advocates for their loved ones. Open discussion between the ‘Clinical pathways increase the involvement of residents and interdisciplinary healthcare team their families in health and and each resident (and his or lifestyle decisions—thus her family) assists in identifying enhancing informed choices. Clinical pathways increase the involvement of residents and their families in health and lifestyle decisions—thus enhancing informed choices. The assessment process helps to identify individual abilities and limitations. Clinical pathways in residential aged care encourage family members to provide . Such mutually ‘Care must be taken to avoid agreed goals and outcomes should setting unrealistic goals. Agreed goals on individual clinical pathways facilitate the planning of activities that enable residents to achieve desired outcomes within an agreed timeframe.’ reflect the declining abilities of residents. This is particularly true of spouses who have been caring for their partners at home before they enter residential aged care. Involvement of family members is essential if a resident does have severe cognitive impairment that reduces the communication of personal preferences. The involvement of the resident and family is central to the development of comprehensive care that reflects individual needs. and care must be taken to avoid setting unrealistic goals.88 Nursing Documentation Resident-centred and outcome-based care The complex health issues that affect people in residential-care settings need to be individually assessed. Involving residents in their care and lifestyle decisions can be quite a challenge if the resident has cognitive impairment (such as that caused by dementia). and realistic goals and individual outcomes of interventions must be planned for each resident.

3) has noted. aged-care nurses often feel that: … reams and reams of documentation are required to justify a pittance in funding to employ staff. Clinical pathways also improve ‘Clinical pathways improve the care-transition process in progressive the care-transition process illnesses such as dementia. and assist in the setting of realistic goals that allow for progressive decline in abilities. documentation skills vary according to staff training. and thus assist both the resident and family members during the transition from home to residential care. p. and that documentation is guided more by a need to justify funding requirements than by a desire to communicate continuity of care to colleagues. The skill mix among staff in residential aged-care facilities means that guidelines are required to ensure that a consistent level of care is provided by all staff. Streamlined documentation Nurses who work in residential aged care often complain that they are so busy making sure that they document care that they do not have enough time to perform actual nursing care. . Anecdotal evidence suggests that nurses working in residential aged care facilities over-document. As Brereton (1999. and are more able to accept the inevitable decline in their loved one’s abilities. Clinical in progressive illnesses. Clinical pathways in residential aged care also provide families with a record of their loved one’s care that they can keep at home and discuss with other family members and friends—thus explaining the holistic care being provided.’ pathways facilitate increased resident and family involvement in nursingcare planning. who. Similarly.89 Clinical Pathways input into the resident’s nursing care. at the end of their more-often-thannot extended unpaid shifts are both physically and mentally exhausted attempting to meet basic care needs for their resident. Family members thus gain an increased understanding of the progressive nature of cognitive impairment.

90 Nursing Documentation Clinical pathways might be a solution to the documentation challenge currently being faced by nurses in residential aged-care facilities. All of these factors are likely to increase professional morale in the team. and promotes regular residential aged care assist the process of continuous interdisciplinary review of care. Clinical pathways guide assessment and care-planning. quality improvement. Setting timeframes to guide interventions and achieve outcomes on a clinical pathway in aged care allows monitoring of progress over realistic ‘Clinical pathways in timeframes. and provide an evidencebased framework that can be used by clinicians to structure their clinical and managerial decisions. nursing care increases and the time spent documenting that nursing care decreases.’ and made consistent across all disciplines and skill levels. Staff satisfaction Clinical pathways can increase morale among members of the interdisciplinary healthcare team by providing them with evidence that their care is consistent with recognised best practice in seeking to achieve the best outcomes for residents. If clinicians working in residential aged-care facilities have access to the appropriate professional tools. Evidence-based practice and continuous quality improvement Evidence-based clinical pathways enable health professionals to review their current practice in relation to accepted best practice. The documentation ‘Nursing care increases and the time spent documenting that process can be streamlined nursing care decreases.’ Clinical pathways in residential aged care assist the process of continuous quality improvement and promote an approach to patient care that focuses on health outcomes and the principles of best practice. .

• arrange meetings with all disciplines and departments. • select a design team. • clarify goals and objectives for introducing pathways. • perform a study of case histories. • select a project coordinator. The committee should: • appoint a chairperson. 2. • select a case or procedure. 1. • perform a literature review. Each of these is briefly described below. • organise a meeting schedule. eleven steps are crucial to successful design and implementation of a clinical pathway. and • set guidelines and clear boundaries for the project. and • select another diagnostic-related group or procedure. These steps are: • select a steering committee. Select a steering committee The committee should include key stakeholders from the clinical and management spheres—and a consumer representative. • trial (first draft). • develop content and design of clinical pathway (first draft).91 Clinical Pathways Design and implementation of clinical pathways Regardless of the size of the organisation and the availability of resources. • refine clinical pathway. Select a project coordinator The project coordinator should have a clinical background and have expertise in: .

The team should: • appoint a chairperson. Perform a literature review A review of the literature should be performed to determine best practice. • organisational change. Arrange meetings with all disciplines and departments Input into the clinical pathway should be encouraged. • organise a meeting schedule. An ongoing education program should be implemented for all staff in the organisation—to ensure that the aims. and progress of the project are understood. The content of the clinical pathway will develop through a collaborative process involving meetings with members of the interdisciplinary team involved in the care of the selected type of case. 4. Select a case or procedure A case or procedure should be selected as the basis for designing a pathway. for the selected case or procedure. . and • coordinated care systems. Critical events and problems in the process of care should be identified. based on evidence. 6. 7. Perform a study of case histories A study of case histories identifies current practices for the selected type of case or procedure. 3. Select a design team A design team should be selected. objectives. The team should include permanent members of the interdisciplinary healthcare team involved in caring for the chosen type of case. 5. and • clarify goals for introducing the pathway.92 Nursing Documentation • project management.

• refine clinical pathway. • identify critical events in the process of achieving desired outcomes. • arrange meetings with all disciplines and departments. Each of these is discussed in this section of the text.93 Clinical Pathways Design and implementation of clinical pathways Regardless of the size of the organisation and the availability of resources. • identify activities required to accomplish outcomes. 8. • perform a literature review. • select a design team. • select a case or procedure. . • trial (first draft). • develop content and design of clinical pathway (first draft). eleven steps are crucial to successful design and implementation of a clinical pathway. and • draft variance-analysis tool and procedures. • perform a study of case histories. • chart the events and activities in a sequential manner to form the pathway on one axis (usually vertical) and time (or other indicators of clinical progression) on the other axis. and • select another diagnostic-related group or procedure. Develop content and design of clinical pathway (first draft) The design team should: • identify desired outcomes. These steps are: • select a steering committee. • select a project coordinator.

Design and implementation of clinical pathways is resource‘Organisations need to consider intensive. quality health care to patients. 11. Select another diagnostic-related group or procedure Another diagnostic-related group (DRG) or procedure should be selected for design and implementation of a new clinical pathway. . The clinical pathway should be reviewed regularly and frequently.’ gain and how they are going to achieve (and sustain) these improvements. and the implementation of continuous quality-improvement processes. and refined drafts should be trialled. Refine clinical pathway The process of refinement of the clinical pathway through variance analysis is ongoing. and the outcomes expected. The success of clinical pathways in other healthcare settings suggests that residential aged-care facilities have much to gain from their implementation. Conclusion Clinical pathways enhance the delivery of efficient. Exclusion of any of these steps increases the risk of clinical pathways not achieving desired outcomes. the timeframe. organisations need to gain and how they are going to consider carefully what they hope to achieve these improvements.94 Nursing Documentation 9. outcome-based aged care. and they have therefore been adopted by many healthcare services as a standard professional process. The above process is then repeated. Much can be learnt from the experience of acute and subacute healthcare settings— and residential aged-care facilities can modify and utilise this information when designing clinical pathways suitable for their own use. Before committing to their carefully what they hope to introduction. The advantages are the development of resident-centred. 10. Trial (first draft) A trial of the pathway is conducted with a view to ascertaining whether the pathway accurately represents the sequence of events.

95 Clinical Pathways Successful implementation of clinical pathways requires organisational commitment to make the changes required. The introduction and implementation of the new process must be carefully planned and managed. . Clinical ‘Clinical pathways are powerful pathways that result in a coordinated tools for ensuring the optimal continuum of care are powerful use of resources and the tools for ensuring the optimal use provision of quality care.’ of resources and the provision of quality care.


and it has been stated that ‘… up to 70% of patients who become delirious are never recognised by physicians or nurses as being in a delirious state’ (Morency et al. 1999). However. If true. nurses can easily slip into automatic note-taking—making repetitious notes as the behaviours and responses of the residents become almost routine. p. 1994. 24). in caring for aged and long-term residents in residential settings. It is essential that nurses recognise the nuances . This is a serious claim.Chapter 7 Documenting Behaviour and Emotion Felicity Humble Introduction All nurses experience and observe the behaviour and emotion of those in their care throughout their work day. Whether these behaviours and emotions are expected or unexpected. nurses have a responsibility to observe them carefully and to record accurately what they have observed. In some cases it is possible for nurses to see only what they choose to see. Nurses document their observations on most shifts on most work days. it is important that nurses involved in aged care take steps to ensure that their recognition and documentation of such behavioural change are improved. Quality resident care depends on the accuracy of these records (Martin et al.

and these emotions are very personal experiences. nurses have a professional responsibility ‘Nurses must be alert to behaviour to observe emotion and behaviour that is inconsistent or unexpected. it is sometimes the resident—to try to empathise with necessary to take a broader what the person is feeling. if the person is unable to express those emotions—because of cognitive impairment from dementia. When anger or frustration is experienced. Empathy Observing and understanding emotions requires nurses to put themselves in the situation of the resident—to try to empathise with what the person is feeling. . Recognising clues When a person is tense and anxious he or she might experience ‘butterflies in the stomach’. social. or because the person is simply not in the habit of discussing feelings—it might be necessary to use other means to understand what he or she is feeling. sweaty hands. They must be alert to behaviour that is inconsistent or unexpected.’ perspective of the resident’s situation. Emotion All behaviours have underlying emotions. a person might experience tightness in the jaw or shoulders. or headaches. Knowledge of the person’s personal. However.98 Nursing Documentation of human emotion. In general. and unrecognised pain are to be diagnosed and managed appropriately. and the behaviour that comes from the expression of that emotion. If disabling conditions such as delirium.’ astutely—and to document their observations accurately. In attempting to ‘ … to put themselves in the situation of empathise. the most reliable way to ascertain what a person might be feeling is to ask him or her. depression. and medical history can be very useful in understanding emotional state and changes in behaviour.

and perhaps become quite restless. It is important for nurses to remember that people with cognitive impairment experience similar feelings to those experienced by people who are not cognitively impaired. especially the expression on the face. but this relies . Is there something on your mind?’ • ‘You seem a bit tense.’ be converted into behaviours—and thus expressed unconsciously. Recognising these ‘clues’. and the best way is to ask the resident. can give clues as to the emotion being experienced by a person. and interpreting them as expressions of internal emotional feelings. Many people in the general community live with this lack of awareness of their own emotional feelings. It is rare for residents with cognitive impairment to identify and express emotions ‘People with cognitive impairment in a verbal or conscious way. requires a high level of self-awareness. but this lack of awareness is further complicated if a person is cognitively impaired. nurses should use simple language that allows the resident to answer in equally simple terms. Some examples of such questions include: • ‘You look worried. experience similar feelings to those Rather. Asking questions In asking questions about feelings. the feelings are likely to experienced by people who are not cognitively impaired. and other people often notice that a person is upset before that person actually realises it. As shown in the table. the outward appearance of emotion can be misleading and does not necessarily give a clear indication of the emotion underlying the facial expression. Further exploration is required.1 (page 100) shows examples of changes in facial expression when a person is experiencing anger or anxiety. The affect. Are you worried?’ • ‘You don’t look happy today.99 Documenting Behaviour and Emotion feel hot. Table 7. Putting the question more openly might give rise to more information. Are you feeling frustrated?’ These questions seek replies that are simple to express.

It requires the person to be able to handle concepts. If asking questions fails to elicit useful information. The ability to utilise empathy can be a very valuable skill. are more likely to be successful in initiating conversation. and to be open in expressing personal feelings. as well as the emotions of those in their care. the nurse must be astute in observing and assessing the behaviour of the resident. They should also be prepared to deal with their own emotional responses.100 Nursing Documentation Table 7. but it does require nurses to remain objective in making assessments about their own emotions. . to be aware of differences. ‘Closed’ questions. An example of such a question might be: • ‘You don’t seem yourself today—can you tell me how you are feeling?’ This type of ‘open-ended’ question cannot be answered with a simple monosyllabic reply. This sort of question is unlikely to be successful if addressed to people who have a cognitive impairment. Nurses need to be prepared to deal with any answers they receive to these questions. Being able to empathise can give aged-care nurses real insight into the experience of the resident. such as those outlined above. especially in caring for people who have a cognitive impairment and who might therefore have difficulty expressing their feelings.1 Outward signs of emotion AUTHOR’S PRESENTATION Anger Frowning Clenched teeth Tearfulness Intense focus or staring Tension in jaw Pulsing carotid in neck Flushed or pale face Anxiety Wrinkled brow Twitching Lip-biting or lip-quivering Sweaty face Dry mouth Trembling or shaking Flushed or pale face on the person being able to verbalise freely.

Figure 7. descriptive terms of general behaviour (such as those listed in Figure 7. and knowledge of previous behaviour patterns can help nurses to detect changes. friends. become aggressive and easily irritated over seemingly trivial incidents.1 (page 102) lists some of the descriptors of general behaviour. and even neighbours are often able to assist in the creation of a ‘profile’ of the person before his or her admission to the aged-care facility. The change should be noted. every person is an individual. Documenting behaviour Recording actual behaviour To provide useful records in nursing notes. an ageing individual who has lived quite a conventional life might begin to reveal rather eccentric tendencies not previously observed.’ behaviour. Family members. Nurses must be careful not to generalise too ‘Nurses must be careful not often. These general behaviours can be closely linked to the personality of the person. every is always useful to attempt to gain an person is an individual. It to generalise too often. Knowledge of previous behavioural patterns can thus help nurses to understand those in their care. It shows that a range of words can be used to describe any given behaviour. For example.’ understanding of what an individual’s behaviour has been like in the past. with the onset of dementia. For example.101 Documenting Behaviour and Emotion Behaviour Describing behaviour There are many types of behaviour and it is important to be able to identify and describe behaviours that might be associated with illness. a person who has been very ‘controlling’ in earlier life might. Such knowledge ‘Knowledge of previous behavioural patterns can help nurses to can also help nurses to understand understand those in their care.1) should be accompanied by . The choice of words is very important in accurate documentation—as will be discussed below.

• ‘Towards evening. describe.102 Nursing Documentation Cooperative Sociable Conventional Consistent Busy Isolated In character Independent Controlling → → → → → → → → → Uncooperative Suspicious Eccentric Unpredictable Idle Intrusive Out of character Passive Aggressive Figure 7. and record such behaviours for the benefit of all nurses involved . He stumbled. Documentation should give other nurses a clear indication of how residents are responding to events around them.1 Descriptions of behaviour AUTHOR’S PRESENTATION accurate recording of actual behaviour. this is out of character with his usual cooperative behaviour’. Mr X was observed to be deteriorating when walking. For ongoing consistent management. Examples of helpful descriptions of general behaviour might be: • ‘Mr X began to swear when being assisted with showering. or • ‘Ms X showed negative body language by turning away from her visiting relative’. but managed to regain his balance and did not fall’. attempting to pull the nurse’s hair’. it is important to observe. • ‘Mrs X showed an aggressive response to assistance with dressing.

People management of dementia. who are depressed can be slow. it can be quite difficult for those with a cognitive impairment to let nurses know of increased pain. Consideration also needs to be given as to whether behavioural changes occur at particular times of the day. and other mood-altering conditions. depression. with people starting the day quite normally and then losing their energy and willingness to socialise with others during the afternoon and evening. and sleeping should also be carefully observed and recorded.103 Documenting Behaviour and Emotion in the care of the residents. Aged-care nurses need to be aware of the ‘sundowner syndrome’—a term used to describe the phenomenon of people with dementia becoming increasingly confused towards late afternoon or evening. Observing and recording these variations over time can facilitate diagnosis and management of dementia. Recording change The general behaviour of all residents ‘Recording what is actually should be regularly and frequently seen and heard creates a picture reviewed—with a view to detecting of the resident—a picture with any change that requires investigation. not simply food and . depression.’ For example. Documenting basic functions The basic functions of eating. Frequent reviews of behaviour will help to identify pain that might otherwise go undetected. but become more energised and lighter in mood as the day progresses. Conditions such as depression can also contribute to a change in emotions and behaviours over ‘Observing and recording variations over time can facilitate diagnosis and the course of a day. which others can relate. It is very important for nurses to be aware of the eating patterns of residents—including consideration of appetite. Sometimes this can be reversed. drinking. and other mood-altering conditions.’ apathetic. Recording what is actually seen and heard creates a picture of the resident—a picture with which others can relate. and miserable in the morning.

or depression. It will alert others to any alterations in the resident’s usual behaviour. • whether the resident took frequent naps during the day.’ . Useful information might include: • how long the resident slept. The problem might be ‘To be meaningful and helpful as simple as ill-fitting dentures or as for other nurses. • ‘ate the entire meal.104 Nursing Documentation fluid intake. • ‘ate soft foods more easily than unprocessed food’. If changes become evident—such as excessively deep sleep during the day. or wakefulness at night that is not easily explained—further investigation might be warranted. delirium. A useful way to record such information is to concentrate on how a person eats—that is. ‘Concentrate on how a person eats … not merely the end result of how much was eaten. • whether the resident could be easily roused. detail than an inadequate To be meaningful and helpful description such as “slept well”. the behaviour associated with eating— not merely the end result of how much was eaten. but ate the whole meal eventually’. documentation serious as a bowel obstruction that of sleep patterns requires more requires urgent treatment. but in very disorganised manner’. If there is a change in a resident’s eating pattern. Examples of useful ways to describe eating behaviours include: • ‘asked for more food after eating’. but did not eat facility food’. and • whether the resident felt rested after sleep. documentation of sleep patterns requires more detail than an inadequate description such as ‘slept well’. This is relevant and important information—and should be recorded. • the times at which the resident fell asleep. • ‘slow to start eating.’ for other nurses. this might indicate a problem that requires further investigation—such as pain. and • ‘ate all food brought by relative. • ‘picked at food and left most uneaten—has a better appetite at lunch than at evening meal’.

Although Doreen rarely spoke. she was normally cooperative with nurses and freely mixed with other residents at mealtimes. (continued) . and recalled that Doreen’s friend and roommate had been transferred to the local hospital on the previous day.105 Documenting Behaviour and Emotion The accurate recording of basic behavioural functions such as these is of the utmost importance in professional aged-care nursing documentation. One day. looked at the nurse. Quite concerned at the change in Doreen. but she slapped the nurse’s hand away. Doreen Doreen suffered from dementia and had been in residential care for several months. Doreen pulled away. below) illustrates many of the topics discussed in this chapter. A case study This chapter has discussed many aspects of the importance of observing and recording emotions and behaviour in aged care. The nurse noticed that Doreen looked paler than usual. The nurse attempted to smooth Doreen’s hair and feel her forehead. the nurse noticed the recently vacated bed next to Doreen’s bed. The nurse offered to bring a fresh cup of tea. Her daughter had arranged Doreen’s admission. Looking around the room. a nurse entered Doreen’s room and found her staring out the window with her cup of tea untouched on her bedside table. The story of Doreen (see Box. The nurse asked her if something was wrong. She was moistening her lips with her tongue. but again Doreen made no reply. When the nurse reached to touch her hand. but said nothing. Doreen turned from the window. but visited only occasionally. the nurse returned to the nurses’ station to review Doreen’s notes. and that she had been uncharacteristically awake and restless during the night. She read that Doreen had not eaten her breakfast (despite being given her favourite meal of porridge). and her forehead was furrowed. who had previously been uncomplicated and cooperative.

the nurse noticed that Doreen was looking at her intently. The nurse again offered to make Doreen a drink. when her daughter had briefly visited. This time she tentatively smiled and held out her hand to the nurse. but there was no particular reaction from Doreen. The nurse sat with Doreen for ten minutes and chatted with her— even though Doreen still made no response. and she had recovered sufficiently to return. However.106 Nursing Documentation (continued) Doreen had also been observed to have been in tears during the preceding evening. with the constraints of heavy workloads. The nurse on the previous shift had said that Doreen was in a ‘bad mood’ that day. There was no record in Doreen’s file as to the likely cause of her distress. no matter how hard it might be to extract a clear response. An astute nurse will have recognised that mentioning the absence of Doreen’s friend was the stimulus that induced the most significant response from the unhappy old woman. The nurse informed Doreen that her roommate would be returning later that day. it is not always easy for nurses to follow up these matters as they would wish. bringing fresh drinks to her each time? • Make some time to sit with Doreen and talk about her daughter’s visit and the absence of her friend? • Telephone Doreen’s daughter and ask what she had done to upset her mother? The best solution is the third alternative. poor communication in cognitively impaired people. This requires further exploration. At this point. In Doreen’s case. what approach would be most appropriate in attempting to clarify the situation? • Ignore the changes in Doreen and get on with other work? • Keep checking on Doreen. The nurse mentioned that she knew that Doreen’s daughter had visited the day before. There is no doubt that the chances of resolving Doreen’s situation would be considerably improved by involving Doreen herself in the process. . and insufficient time to accomplish all the tasks associated with aged care. Her minor operation had been successful.

• The recording of such information is as important as any other aspect of a resident’s health status.’ up in an appropriate and sensitive manner. diagnosis. weeks. or even months of impaired health or lifethreatening illness. it is imperative that emotion and behaviour are observed and recorded accurately and descriptively. the case study shows that the astute observation of emotion and behaviour. . Documentation of emotion and behaviour This chapter has considered many aspects of observing and recording emotion and behaviour in an aged-care setting. • Even if residents are unable to relate what they are feeling.107 Documenting Behaviour and Emotion However it is handled. Prompt and accurate observation and documentation facilitate early detection. and treatment. The main points of the chapter can be summarised as follows. together with accurate problem will be followed nursing progress notes. Conclusion To facilitate the most comprehensive and appropriate care for residents in aged-care facilities. It is important for nurses to know that the onset of delirium can occur over only a few hours. together with reference to accurate nursing progress notes. make ‘ … the astute observation of emotion it more likely that Doreen’s and behaviour. there are often behavioural clues that indicate their emotions. and appropriate investigations and management are more likely to ensue. • Accurate and comprehensive records of changes in emotion and behaviour assist in detecting deterioration in both physical and emotional states. • Nurses have a professional responsibility to observe and record the emotions and behaviours of those in their care. Subtle (and notso-subtle) changes in a resident’s behaviour will then be noted and communicated. but that a failure to recognise it and investigate it can result in days.

but accurate professional documentation of behaviour and emotion can help to overcome the difficulties associated with these communication difficulties. . the nursing notes will reveal clear indications of a gradual deterioration in the person’s mood. However.’ enormous rewards for all concerned.108 Nursing Documentation A depressive illness can take weeks (or even months) to become apparent. This is one of the ‘Documentation is one of the greatest challenges of agedgreatest challenges of aged-care nursing. but meeting the challenge care nursing. Residents with cognitive impairment might not be able to explain what is causing these changes. but meeting the ultimately produces enormous challenge ultimately produces rewards for all concerned. if accurate documentation of residents’ behaviour is maintained.

. especially in the aged-care sector. there has been ‘ … a tremendous increase in the use and availability of complementary therapies in Western countries in recent decades’ (McCabe 2001. 10). The application of such complementary therapies in any healthcare setting involves four stages: • the planning stage. • the implementation stage. 3): The terms alternative. non-traditional. The Nurse’s Handbook of Alternative & Complementary Therapies makes the following observation about the term ‘complementary therapies’ (NHACT 1999. p. unconventional. and unorthodox are used interchangeably … to denote healing practices that have not traditionally been found in Western medical practice or taught in main stream medical schools. complementary. and • the evaluation stage. p. • the organisational stage.Chapter 8 Documenting Complementary Therapies Sue Forster Introduction In contemporary nursing practice.

110 Nursing Documentation The first two stages of complementary therapies in aged care—the planning and organisational stages—are generally included in the position description and role of the person designated as an ‘activities officer’ or a ‘diversional therapist’. • social profiles and assessments. definitive. and protocols General principles All policies. the personnel in these positions are also expected to undertake the third and fourth stages—the implementation and evaluation of ‘Documentary evidence of the therapies—but this does not complementary therapies needs to be meet the tenets of true holistic vigorous. and protocols. and faultless. Each of these is discussed below. procedures. and protocols should reflect current legislative requirements—both national and regional—in the local jurisdiction. In all contemporary nursing practices the need for documentary evidence is well established. In some circumstances. Policies. In any aged-care facility that utilises complementary therapies. and • educational records. • programs. • evaluations. . procedures. the implementation and evaluation stages of complementary therapies should be included in the position descriptions and role statements of all care providers—and all of the stages cited above should be clearly documented in such position descriptions and role statements.’ care. In addition. the required documentation includes: • policies. • consents and authorities. • care plans. definitive. In such holistic care. this documentary evidence needs to be vigorous. procedures. With respect to complementary therapies. and faultless. these policy documents should address ethical considerations. 1.

and guidelines set out by professional nursing bodies and peak group associations. assistance can be ‘ … obtained from nurses’ registration bodies. transport availability. Some aged-care facilities provided by the facility. and complementary therapy associations’ (Quirk 2003. p. These include (as adapted from Quirk 2003): • regimens that will be provided. 229). these should be directly of the procedures and protocols. Practical issues Practical consideration must be given to a number of issues when preparing policy-related documents. procedures. . Regimens that will be provided There should be a separate policy. • qualifications of service providers.111 Documenting Complementary Therapies the needs of the resident. This service directory should stipulate contact details. and protocol documented policy. ‘There should be a separate procedure. and any expenses that might be incurred. In writing such policies. Each of these is discussed below. various nursing associations (including the holistic nurses’ associations). and protocols ensures commitment to the aims of the policies and successful implementation of ‘A multidisciplinary team approach ensures commitment to the aims of the the procedures and protocols.’ linked to the organisation’s vision statement and mission statement.’ formulate a directory of services that is made available both internally and externally. policies and successful implementation In turn. and • occupational health-and-safety issues. • accountability of the organisation. procedure. A multidisciplinary team approach to formulating complementary therapy policies. • resources required. and protocol for each therapy provided by the documented for each therapy facility. professional colleges.

documentation begins with a comprehensive assessment. Qualifications of service providers Unqualified personnel should not provide some complementary therapies. Social profiles and assessments . These costings should be documented in the annual budget submissions. Consumable supplies need replenishment.112 Nursing Documentation Resources required Some equipment and materials that are needed for complementary therapies are expensive. Such legislation usually includes provisions regarding infection control. the second category of documentation in utilising complementary therapies relates to social profiles and assessments. risk assessment and management. Occupational health-and-safety issues Most jurisdictions have specific legislation with respect to workplace safety. All of these matters must be addressed in the policy document. Accountability of the organisation The policy document should state the responsibilities of the organisation with respect to provision of complementary therapies. This document should state how the organisation meets all relevant legislative requirements and whether it provides insurance cover (or whether this is a responsibility of the resident). These need to be purchased. Specific insurance requirements should also be documented. As was noted in the introduction to this chapter on page 110. and so on. a social profile should be completed. the use of protective equipment. Before implementing any complementary therapy. This social profile should be designed to elucidate sociodemographic data that will assist in deciding whether complementary 2. Initially. and regularly replaced or maintained. The policy document should state which therapies require qualified providers and how currency to practise is assured. manual handling. use of chemicals.

and so on. social security details. church groups. and so on. therapies are appropriate in the resident’s care plan. community groups. . gardening. crafts. The information that needs to be obtained and documented in completing a social profile includes: • personal details—name. • care plans.113 Documenting Complementary Therapies Documentation of complementary therapies In any aged-care facility that utilises complementary therapies. cooking. • programs. the required documentation includes: • policies. • social support—relatives. and so on. medications. • likes and dislikes. pets. • consents and authorities. and protocols. • primary and secondary languages. • health status—diagnoses. • previous employment and educational achievement. and so on. other countries of residence. gender. • evaluations. friends. group memberships. • culture—place of birth. age. health behaviours. • spirituality—religion. procedures. A discussion of each of these topics forms the framework of this chapter. address. social activities. • social profiles and assessments. disabilities. terminal wishes and care. and • educational records. comfort activities. • lifestyle activities—ironing. • leisure activities—hobbies.

and • nutritional and hydration status. These additional assessments might include examination of: • behavioural patterns. • communication assessment.114 Nursing Documentation • sensory abilities or disabilities. and • designing a care plan. • pain assessments. This information should assist the assessor in: • conducting any further assessments needed. Programs As noted on page 110.) After completing a social profile. see ‘Consents and authorities’. 3. consent must be obtained before commencing any complementary remedies. page 115. Programs should . • sleep patterns. (For more on this. complementary remedies. • skin condition and wound assessments. • mini-mental examination. The social profile must be compiled from information given by the resident or his or her representative. Some organisations have a requirement that a signature must be ‘Consent must be obtained obtained from the informant as proof before commencing any of his or her input into care planning. and • previous and current experiences with complementary therapies. • drawing up referrals to appropriate therapists.’ Even if the organisation does not require a signature on a social profile. • depression-rating scales. more specific assessments can be carried out and documented. • special senses appraisal. the third category of documentation required with respect to complementary therapies relates to programs. • mobility and dexterity capabilities.

the patient’s other caregivers. All programs should be flexible enough to accommodate any contingency. and the service provider’s name. and the patient. If expenses are to be incurred or if appointments are required. but the former are usually provided by someone other than the resident.’ resident’s routine activities—such as meal times. employers. activities of daily living. 5) has observed: Good documentation should give legal protection to you. Admissible in court as a legal document. 4. An annual and monthly schedule of services should be documented and distributed to residents.115 Documenting Complementary Therapies be designed to inform current and potential residents of the various complementary services that are available. In obtaining authorities. but effective negotiation skills can assist the planner. Authorities are similar to written consents. the date. Programs should offer a variety of activities to maximise individual choice on any given day. residents should be informed before the therapy is provided. and the recipients of care with legal protection in any malpractice cases. Including the annual program in the residents’ handbook can be a valuable marketing tool for the facility. the health care facility. and duration. It provides employees. These are listed in the Box on page 116. Individualising programs in this way can be complex and problematic. Written consent is a very important component of professional documentation. When formulating programs it is ‘It is essential to plan essential to plan therapies around each therapies around each resident’s routine activities. Consents and authorities For written consent to be valid it must conform with certain requirements. rest periods. As Loeb (1992. time. p. the clinical record provides proof of the quality of care given to a patient. The programs should document the type of service. and social appointments. the .

In some jurisdictions consent must be renewed signed. To prevent exposure to professional liability. side-effects. • Mental Health Acts. The original should be filed in the resident’s health record. • given by a person who is deemed to be cognitively intact and competent to give consent. All authorities and consents should be signed. upgraded. A signed consent obtained upon admission might not be legally valid if the resident’s condition deteriorates or if a long time elapses from the date of ‘All authorities and consents should be signing. each signatory should print his or her name . and • given by a person who meets the statutory age requirement within the particular jurisdiction. witnessed.116 Nursing Documentation Valid consent For written consent to be valid it must conform with certain requirements. • informed—the person consenting needs to be given all relevant details. and any known idiosyncratic reactions. including desired effects. and dated. terms of reference of particular statutory Acts must be observed. • Attorney Acts. explicit information must be provided to the signatory before the consent form is signed. Such consent must be: • voluntarily given—not through coercion. and a copy should be given to the resident and/or representative. and • Adult Guardian Acts. and renewed. and dated. witnessed. Examples of these include: • Health Acts. This information should be documented.’ every three months. Written authorities and consents must be constantly reviewed. Following these notations.

This means that specific documentation of care plans is especially important in complementary therapies. . specific documentation is essential. • recipes and prescriptions (if applicable). • objectives of care. • reporting criteria.117 Documenting Complementary Therapies and status (or relationship to the resident). 5. and • evaluative criteria. When complementary therapies are incorporated into a resident’s care plan. side-effects. The Box on page 118 provides guidelines on how to draw up a care plan for aromatherapy. • required observations. Guidelines of this sort can be adapted and applied to the drawing-up of care plans for other complementary-therapy modalities. The majority of staff members have limited knowledge of the intricacies and requirements of the many therapies that fall under the all-encompassing umbrella of ‘complementary therapies’. a limited number of nominated persons are authorised to witness legal documents. In some organisations. In these circumstances. There are few qualified complementary therapists employed within the aged-care sector. • methodologies associated with application. The care plan should include: • treatment regimens. these nominated witnesses must provide the signatory with the necessary information to ensure that informed consent is obtained. Care plans The fifth category of documentation required with respect to complementary therapies (see page 110) relates to care plans. and known idiosyncratic reactions. • desired effects. • when the therapy should be ceased.

biochemistry measurements.The route. This record should take the form of a task analysis. Objectives of care The specific goals should be stipulated utilising a time reference (for example. Methodologies associated with application The specific method of massage or application should be clearly stated. cream. Desired effects. together with the method of application (for example. and the volume and type of base. ‘Mrs A will be less agitated during the night following application of the spray’ or ‘Mrs A will be free of pruritus in one week’). known idiosyncratic reactions Any known reactions should be listed. The reporting criteria should also state whether such an event should be reported to the aromatherapist and/or a senior staff member. Recipes and prescription The number of drops of essential oils. Reporting criteria The aromatherapist should document any event that should be reported. should also be written down. or ingested). or the resident’s condition status) should be documented. continue therapy. and administration should be recorded. or cease therapy. The action to be taken if these things occur should be noted—for example. and the date of review should be included. The required frequency of such observations should be noted. side-effects. (continued) . frequency. The times for application. dose. reduce frequency. spray. the duration of the course. Required observations Any required observations (such as recording vital signs. inhaled.118 Nursing Documentation Guidelines for aromatherapy care plan Treatment regimen The name of the essential oils must be documented.

wound dimensions lessening. erythema absent.’ reactions. rhinorrhoea. diastolic blood pressure below 85 mm Hg. A documented framework can be utilised to assess some aspects of a resident’s involvement in the therapies being implemented. Evaluation As noted on page 110.1 (page 120). The framework is illustrated in Figure 8. The total score for all five criteria is then calculated. increased pulse rate. To measure the actual effectiveness of the complementary therapy being applied. Evaluative criteria The quantitative evaluative criteria should be cited—for example. the assessor should refer to the program objectives and timeframes for evaluative criteria. urticaria.119 Documenting Complementary Therapies (continued) The therapy should be ceased if … Any events that would lead to immediate cessation of the therapy should be documented—for example. 6. the sixth category of documentation required in utilising complementary therapies relates to evaluation. raised blood pressure. pulse rate within normal range. Altered cognition in residents can mean that an assessor is presented with various ‘red herrings’ in evaluating behaviours. Effective evaluation of complementary therapies in the aged-care sector is often difficult to achieve because of the altered cognitive ability of many of the residents. ‘Effective evaluation of complementary therapies in the aged-care sector is often It uses a numerical scale difficult to achieve because of the altered to indicate a continuum of cognitive ability of many of the residents. The measurement criteria might include . volume of sputum diminishing. A score of zero (out of a possible total value of twenty points) indicates that the resident is actively participating in the therapy.

An extended time period is recommended to minimise unrelated changes ‘If the organisation intends to conduct research in complementary therapies. and thus optimise data it is imperative that a contract for validity. and the purpose of the research project. When behavioural participants be signed and witnessed. An ethics committee can assist with respect to the confidentiality of data. These should be documented over a period of 3–7 days. a useful strategy to use is to make anecdotal progressive entries in the resident’s notes on a ‘shift-by-shift’ basis. and • planning future educational activities. • applying industry benchmarking. It is essential to document evaluative data for the purposes of: • conducting research.120 Nursing Documentation 0 Understanding Participation Attention span Anxiety level Social abilities Grasps situation → Acts on own initiative Attentive No anxiety Cooperative → → → → 1 → → → → → 2 → → → → → 3 → → → → → 4 5 → Unable to understand → → → No interest in participating No attention Too anxious to participate withdrawn → Uncooperative and/or Figure 8. If the organisation intends to conduct research in complementary therapies. it is imperative that a contract for participants be signed and witnessed. psychological reactions. the right to withdraw.’ changes are the goal of the therapy. and social interactions. . All of these matters should be properly documented. the sharing of results.1 Continuum framework for assessment of resident involvement AUTHOR’S CREATION actual physical signs.

learning. and • records of attendance at educational presentations conducted internally or externally. if it applies the applies the principles of adult principles of adult learning. and the learner should be precluded from activities related to application of the subject matter. Documentation of education in complementary therapies should include: • the results of a recently completed needs analysis. residents. Failure to achieve competence should also be documented. Another documentary requirement related to the topic of education is that the organisation should have anti-discrimination. • an educational program. and evaluate complementary therapies (and the mandatory qualifications required). qualifications. Educational records .’ Achievement of ‘on-the-job’ and ‘off-the job’ competencies should be documented—and should attract recognition in terms of the appropriate credentials and remuneration. • an educational plan. and if the anticipated learning is evaluated. and whether the participant was paid. implement. volunteers. • lesson plans. Education is effective only if ‘Education is effective only if it is ‘needs driven’. and if the anticipated learning is evaluated.121 Documenting Complementary Therapies The last of the items listed on page 110 was education. and their representatives. and appeal policies in place. and any current required practising certificates. • a statement of who can plan. 7. • a policy related to recognition of prior learning (RPL). • records of achievement. • provision of education to staff. whether attended while on or off duty. • any competency-based training that is being conducted (internally or externally). if it it is ‘needs driven’. grievance.

.122 Nursing Documentation Conclusion The inclusion of complementary therapies in aged-care is essential if the goal of holistic care is to be achieved. aged-care nurses are adequately prepared to meet these important requirements. The next generation will be used to participating in decision-making about their care. Moreover. The documentary requirements might appear to be overwhelming initially. However.’ care will be even more discerning and demanding with respect to their health care than are the current population of residents. Aged-care nurses will need to plan ahead and be proactive if commercial viability is to be maintained. In recent times. and also value being included in decision-making about their care. an increasing number of aged-care residents have experienced the value of complementary therapies before becoming dependent upon service providers. as a result of their experience in accreditation processes and continuous quality improvement (CQI) activities. the members of ‘Aged-care nurses are adequately prepared to meet the next generation to receive agedthese important requirements. These people value the outcomes of such therapies.

Western timely and accurate manner. However. Unfortunately. in agedincidence of conditions that limit a care nursing. depression.’ populations are living longer. delirium.Chapter 9 Documenting Pain Management Michael Cully Introduction The International Association for the Study of Pain defines pain as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage. with 25–50% of elderly people in the community experiencing pain. this latter definition person’s ability to report pain in a is not always sufficient. McCaffery (1968. with the fastest-growing sector of the community being people over the age of 80. Older adults are twice as likely to experience pain than younger adults. or described in terms of such damage’ (APS 1992). and other conditions that limit a person’s ability to report pain in a timely and accurate manner. p. existing whenever he [or she] ‘Accompanying the ageing of the population are sharp rises in the says it does’. accompanying this ageing of the population are sharp rises in the incidence of dementia. . 95) famously defined pain as ‘whatever the experiencing person says it is.

The assessment tool also seeks to establish the resident’s feelings about expressing pain. Appropriate questions include: • Do you have any ongoing pain problems? • Do you have pain now? • Where is the pain located? • What is the intensity of the pain on a scale of 1 to 10? • What is the intensity of the pain now? • What is the usual intensity of the pain? • What treatment.’ a nursing-care plan can be drawn up using data from an initial painassessment tool. what causes the pain. ‘Sometimes residents are reluctant to talk about pain. McCaffery and Pasero (1999) provided an initial painassessment tool to be administered when a resident is first admitted to an aged-care facility. and • the onset. Asking appropriate questions about the pain provides information that helps to determine whether the resident needs a specific pain-treatment plan. duration. • the quality of the pain. Johansson & Johansson 1999). do you have for your pain? • Is your pain satisfactorily controlled now? If the responses to these questions indicate the need for specific treatment. and the effects of the pain. The initial pain-assessment tool also determines what brings relief from the pain. variation. This gives . • the intensity of the pain.124 Nursing Documentation As many as 85% of elderly people in residential facilities experience pain. Assessing pain on admission The management of pain begins with a comprehensive nursing assessment. and there is a well-documented pattern of under-treatment of that pain (Gaston-Johansson. or rhythms of the pain. Sometimes residents are reluctant to talk about pain. if any. It asks the resident to identify: • the location of any pain he or she might have.

4 being large pain. A second tool.125 Documenting Pain Management a resident the opportunity to add any additional information that he or she feels might be relevant. The Box on page 126 provides guidance on how to link an initial pain assessment with documentation. 3 being medium pain. and 5 being the worst possible pain’. • mood. • sleep. Taken together. • activities of daily living (ADLs).’ The scale can be used by the nurse who simply says: ‘Describe how much pain you have by picking a number between 1 and 5. with 1 being ‘no pain’ and 5 used with a resident who has the being ‘the worst pain imaginable’. Rating scales Numeric rating scale A numeric rating scale is accepted as having good reliability and validity as a pain-rating tool when used with a resident who has the capacity to understand it. This inventory uses a 10-point visual analogue scale for most items. • mobility. 2 being a little pain. capacity to understand it. and • enjoyment of life. • social relationships. with 1 being no pain. . concentrates on the resident’s pain experience over the preceding 24 hours and its effect on: • general activity. It asks a resident to rate his or her pain on a scale of 1 ‘A numeric rating scale has good reliability and validity when to 5. the initial pain-assessment tool and the brief pain inventory can provide essential information for formulating a plan for pain management. called the ‘brief pain inventory’ (McCaffery & Pasero 1999).

(continued) . 3.). Intensity of pain Suggested question: • On a scale of 1 to 10. Character or quality of pain Suggested questions: • In your own words. how would you rate your pain now? Suggested documentation: Document with pain-rating scale and include description of scale (for example.126 Nursing Documentation Linking initial pain assessment with documentation 1. Onset and duration of pain Suggested questions: • • • • • When did the pain begin? What were you doing when the pain began? How many days. 4. etc. ‘throbbing’. how would you describe the pain? • Does anything make the pain better or worse? Suggested documentation: Document resident’s words (‘burning’. ‘cramping’. or months has the pain been present? How often do the episodes of pain occur? How long do the episodes last? Suggested documentation: Document by quoting the resident. ‘stabbing’. weeks. 1 is no pain. 2. 10 is the worst pain imaginable). Location of pain Suggested questions: • Where is the pain located? • Does it radiate or spread elsewhere? Suggested documentation: Document with figure drawings.

route. 7.127 Documenting Pain Management (continued) 5. Other Suggested question: • Is there any thing else you would like to add? Suggested documentation: Document by recording the resident’s responses. 9. 6. ADAPTED FROM BEMIS & ARMSTRONG (2001) . Therapy Suggested questions: • Do you take any pain medications or use pain-relief measures? • If pain medications are taken. dosage. 8. and frequency of the medication? • Do they help? Suggested documentation: Document by recording the resident’s responses. what is the name. Effects of pain Suggested questions: • Are you able to sleep and rest? • Are you able to perform your daily activities? Suggested documentation: Document by recording the resident’s responses. Associated symptoms Suggested question: • Are other symptoms associated with the pain? Suggested documentation: Document by quoting the resident. Causes of pain Suggested questions: • Do you know the cause of the pain? • Does anything in particular bring the pain on? Suggested documentation: Document by recording the resident’s responses.

2 (below).1 (below).128 Nursing Documentation It is a better idea to use a visual analogue scale that contains the same information. 1 No pain → → 2 Little pain → → 3 Medium pain → → 4 Large pain → → 5 Worst possible pain Figure 9. as illustrated in Figure 9.1 A 5-point visual analogue scale AUTHOR’S CREATION 1 No pain → 2 → → 3 → → 4 → 5 → 6 → 7 → → 8 → → 9 → 10 Worst pain Moderate pain Figure 9. • involve family members. .2 A 10-point visual analogue scale AUTHOR’S CREATION The Australian government’s Department of Veterans’ Affairs (2000) gave the following useful hints on using a numeric rating scale: • allow sufficient time to elicit a resident’s self-reported pain rating. • provide an environment that is quiet and free from distractions. enlarged numeric rating scale charts and enlarged anatomical charts for pinpointing pain location. as illustrated in Figure 9. • have appropriate visual and hearing aids available—for example. The scale can also have ten points. and use appropriate volume. • speak slowly and clearly.

If a resident has known cognitive impairment. • slight smile. and should repeat the scale at least three times (McCaffery & Pasero 1999). crying face = hurts worst. ask residents to point to the enlarged scale or anatomical drawing (if they cannot respond verbally but can understand the process). it has proved to be effective when used with elderly adults who have cognitive or expressive difficulties. the Wong– impairment. flattened eyebrows = hurts a little bit. nurses should allow 30 seconds for each response. The scale is described in the Box below. Although this scale was developed for very young children. teach residents how to use a pain-rating scale. A resident is given the following alternatives: • broadly smiling face = no hurt. distressed face. . explain the use of the scale each time it is administered.129 Documenting Pain Management use enlarged copies of a numeric rating scale. and should Baker ‘faces rating scale’ can repeat the scale at least three times. • distinct turning down of mouth and eyebrows = hurts a lot. mouth a straight line = hurts a little more.’ be used (Wong 1997). and • clearly distressed. use the same pain-rating scale each time it is administered. and • ask residents to provide a single global estimate of pain intensity. • mouth beginning to turn down. nurses should allow 30 seconds for each response. • • • • • Wong–Baker scale The Wong–Baker ‘faces-rating scale’ (Wong 1997) uses six facial expressions—ranging from a face that is smiling broadly to a crying. eyebrows turning down = hurts even more. If it is not possible to use a ‘If a resident has known cognitive numeric rating scale. • no smile.

not the experience of pain. patterns of daily activity.’ of pain. Such a mistake could result in inappropriate treatment. • • • • • • The following matters should be documented: the medical history. . It is a valid and reliable tool that can be used with cognitively intact residents. and the clinician must therefore take responsibility for ensuring that the purpose of the scale is clearly understood. Because it is complex and takes longer to administer than other tests. sleep patterns. Documentation and unrecognised pain Many residents have difficulty in providing accurate and reliable selfreporting of pain. mental state. not the experience mood. some concern has been expressed that an elderly adult might mistake its intention if the scale is not properly explained.130 Nursing Documentation Although this scale has been translated into many languages and is popular with clinicians. It includes an extensive questionnaire and body drawings that invite a resident to indicate exactly where the pain is occurring. nutrition. McGill pain inventory The McGill pain inventory is another pain-assessment scale that is used widely for documentation (Melzack 1987). it is less appropriate for residents with impaired cognitive functioning. and whether it requires management. Nurses should therefore always consult existing documentation to establish whether pain is likely to be present. The person might believe that the ‘An elderly person might believe that faces scale is measuring his or the faces scale is measuring his or her her mood. emotional state.

Apart from the above. and • peripheral neuropathies. guarding of anatomical areas. When assessing whether pain exists. nurses should be in the habit of checking residents’ records for any . It should also be remembered that. Nurses should pay particular attention to nursing entries that describe grimacing. occult fractures. These matters should all be carefully documented. but other common causes include (Bemis & Armstrong 2001): • degenerative joint disease of other types. Nurses should ask themselves: • whether the resident has fallen recently. so other signs must be recognised. Late-stage dementia masks facial grimacing. Nurses should always be alert to the possibility of pain being associated with a range of chronic and acute illnesses. and marked changes in activity levels. nurses need to look for documentation of co-existing painful conditions that might not have been the primary reason for the admission. In the medical history.131 Documenting Pain Management • patterns of wandering. and strains are common causes of unrecognised pain in the elderly. • crying out and/or aggression. Moreover. sprains. nurses must therefore make judgments on the balance of probabilities—and must undertake appropriate investigations accordingly. sighing. • peripheral vascular disease. even in the absence of dementia. The most common cause of pain in elderly people is osteoarthritis. behavioural and physiological adaptation to pain often occurs. and this can mask signs of chronic pain (McCaffery & Pasero 1999). and • whether there has been a sudden change in levels of mobility and activity. and • changes to the level of social functioning.

These include: • osteoarthritis. this might lead to an astute nurse detecting a should prompt further previously ignored problem. These include beliefs that pain is: • an inevitable part of the ageing process. • a sign of the development of life-threatening conditions such as cancer (which activates denial mechanisms). Nurses should also be alert to: • unrecognised pain associated with a range of chronic and acute illnesses. Such a routine check might lead to an astute nurse detecting a previously ignored problem. residents often hold beliefs that lead to under-reporting of pain.132 Nursing Documentation notes about these sorts of matters. Such a routine check might lead to an astute nurse detecting a previously ignored problem. sprains. and • peripheral neuropathies. Common causes of pain in the elderly Nurses should always keep in mind the most common causes of pain in the elderly. Barriers to effective communication and documentation Myths Many myths exist that lead to the under-treatment of pain. . • degenerative joint disease of other types. and strains. and • unrecognised pain associated with occult fractures. Perhaps the most harmful myth is that residents readily report their pain to nurses. If anything of significance is found ‘A routine check of documentation in the records. Nurses should be in the habit of checking residents’ records for any notes about these sorts of matters.’ investigation. • peripheral vascular disease. In fact.

133 Documenting Pain Management • likely to cause inconvenience or distress to others. and alterations in elimination patterns. Barriers to effective documentation This section of the text discusses various potential barriers that might inhibit accurate detection and documentation of pain. and • erroneous beliefs held by nurses. Nurses should always keep the following potential barriers in mind: • common myths about pain in the elderly. Nurses should check existing documentation for evidence of anxiety or depression. • a punishment for past sins. Education An essential part of any admission is educating residents and their families about the need to identify and ameliorate pain. increased sleepiness during the day (or broken sleep at night). • a lack of education about pain. while at the same time increasing the experience of pain. • the possibility that depression and anxiety might be present. This could include reports of social withdrawal. • to be preferred to medical treatments that have intolerable sideeffects (including addiction). Each of these is discussed in this section of the text. changes in appetite. and culturally appropriate terms—the ways in which the management of pain . The documented plan should address any concerns expressed by the resident. and should outline—in simple. Such an education plan is also an essential part of pain documentation. These conditions can diminish a resident’s ability to communicate his or her pain. or a purification process. understandable. • difficulty in finding the right words to describe pain. and • to be borne stoically—that is. Depression and anxiety Nurses need to be aware that residents might be depressed or anxious. without complaint.

If detected. Suggestions such as these help the resident to communicate his or her experience. In fulfilling their professional responsibilities in . education plans must incorporate sessions ‘Nurses can hold unhelpful and incorrect on pain management that beliefs that interfere with pain reporting. it is perfectly justifiable for nurses to suggest words to describe the pain—for example. • that the presence and intensity of pain can be accurately gauged by reference to vital signs. ‘throbbing’. Finding the right words Another barrier to communicating pain levels is that residents can have difficulty in finding the right descriptive word. this should be recorded in the notes.’ reflect best practice. However. ‘burning’. These sessions should be based on acceptable levels of evidence and. if a nurse must help the resident find the ‘right’ word. Such an education plan forms part of the essential documentation of any pain-management strategy. if appropriate. ‘dull’. ‘crushing’. should include advice on values clarification and cultural awareness. Nurses should examine pain documentation for evidence of unhelpful attitudes and beliefs of nurses in the facility. Procedures for pain documentation Documentation of pain is obviously a very important aspect of overall nursing documentation. ‘aching’. In these cases.134 Nursing Documentation will be approached. These include: • that older residents and cognitively impaired residents have lower levels of pain. and so on. • that certain ethnic and cultural groups persistently over-report or under-report pain. and • that over-reporting of pain is a diagnostic sign of opioid addiction. Nurses’ erroneous beliefs Nurses can also hold unhelpful and incorrect beliefs that interfere with pain reporting. ‘sharp’. ‘stabbing’.

As a rule. • ensuring that entries are in the correct chart. • avoiding the use of ‘whiteout’ or erasers. These include: • writing legibly in ink. Standard documentation procedures Apart from the specific procedures noted above. if an elderly resident is too disabled to communicate his or her pain status voluntarily and clearly.135 Documenting Pain Management this area. there are certain procedures that nurses should follow. • correcting errors in a proper manner—drawing a single line through any error. • not making new entries between lines. writing ‘mistaken entry’. • proposed changes to the nursing-care plan in the light of resident responses. • a nursing-care plan for the management of the pain. • communications with other members of the healthcare team. Some of these are specific to pain documentation. and • resident and family education on pain control—especially as part of pre-discharge planning. whereas others are of a more general and standard nature. • interventions and resident responses. • completing documentation as soon as possible after assessing the resident’s pain. and initialling the correction. Specific procedures for pain documentation To be comprehensive and effective. • any advocacy undertaken on the part of the resident. documentation of pain should also follow standard documentation procedures. . • the effect of the pain on the resident’s biopsychosocial status. the frequency of documentation needs to increase. documentation of pain must clearly describe: • the nature and level of the resident’s pain. • signing all entries with name and designation.

. the nurse should then ask: ‘What can I do about it?’. In documenting residents’ pain experiences. If the answer is ‘no’. nurses should remember should always remember that that the absence of pain is one of the the absence of pain is one of major determinants of quality of life. providing clear reasons for interventions (and not expecting the reader to be able to make inferential leaps).’ the major determinants of quality of life.136 Nursing Documentation using precise. using the resident’s words wherever possible. non-judgmental language. leaving no blank lines in entries. nurses experiences. and • using only acceptable abbreviations. Nurses should ensure that pain-management documentation is a primary goal in quality-assurance activities. and their ‘In documenting residents’ pain responses to treatment. utilising quotations. One of the essential responses to this latter question is to communicate with other team members through efficient and effective documentation. • • • • Conclusion Nurses must always ask: ‘Is this person pain-free?’.

lap belts. and deep low chairs. It has been suggested that the term ‘restraint’ should be replaced by the term ‘protective assistance’ (Lange 1994). table tops. high fences. electronically operated doors. Chemical restraint involves the use of medications to control behaviours or mood.Chapter 10 Documenting Restraint Sue Forster Introduction Restraint can be defined as the use of any methodology or apparatus that controls a person’s choice to move freely and which cannot be easily removed by that person (Stilwell 1993). The use of this term might . • restraint applied to the environment that effects all residents within the area—for example. vests. Physical restraint can be further subdivided into three categories: • restraint applied to the resident—for example. wheelchair bars. bed rails. mitts. bed tables. binders. • restraint applied to the resident’s immediate environment—for example. Restraint is usually divided into physical restraint and chemical restraint. splints. secure areas or units. wrist ties.

The documentation should also demonstrate a direct link with the organisation’s vision statement. Assistance in writing specific restraint policies can be obtained from governmental regulatory authorities.138 Nursing Documentation assist with a paradigm shift in thinking from custodial or controlling care to holistic and participatory care. and guidelines set out by professional bodies (medical and nursing) and peak group associations. • assessments. the needs of the client. the use of this term would assist policymakers to become more resident-focused. the documents should address ethical considerations. and • educational records. procedures. and guidelines with respect to the use of restraints. and protocols General principles To ensure commitment of all parties to the safe application of restraints. procedures. mission statement. and protocols should reflect legislative requirements in the local jurisdiction. The use of restraint in an aged-care facility requires the following documentation: • policies. Each of these is discussed below. • care plans. and educational bodies. Furthermore. • evaluation. procedures. • other resident documents. policy documents. and protocols. Many of these groups have drawn up specific codes of conduct. and other relevant policy documents. Policies. nurses’ registration bodies. In addition. professional colleges. a multidisciplinary team approach to formulating policies. This should include consumer input. All policies. . procedures. 1. • consents and authorities. and protocols is required. various gerontological nursing associations.

or replenishment. grievance. • other resident documents. gates. . • anti-discrimination. • evaluation. and protocols. These include: • resources required. and medications. the types of resources required might include electronic security equipment. and some staff members. procedures. and appeal issues. and • educational records.139 Documenting Restraint Because the use of restraints is an emotive experience for residents. A discussion of these issues forms the framework for this chapter. Documentation of restraint The use of restraint in an aged-care facility requires the following documentation: • policies. • accountability of the organisation. code pads. sashes. Resources required Resources required for restraint vary according to the policies and practices of the facility. belts. However. • care plans. Practical issues Practical consideration must be given to a number of issues when preparing policy documents. replacement. These are discussed below. • consents and authorities. vests. and • occupational health-and-safety issues. consideration should be given to implementing policies and procedures to produce a restraint-free environment or a minimal-restraint environment. All of them require maintenance. • assessments. fences. their representatives. Some of these are expensive.

‘The use of restraints can have serious legal consequences … charges of The policy document assault and battery might be brought. a senior legal officer has warned that. Each of these matters is discussed in this portion of the text. Anti-discrimination. These include: • resources required.’ should therefore carefully address the responsibilities of the aged-care facility with respect to the use of restraints. These must be clearly documented in annual budget submissions and final budget documents. • accountability of the organisation. in certain circumstances. This is not the place to explore these issues in any detail. with respect to documentation . However. and appeal issues The philosophical. This document should state how the organisation meets all relevant legislative requirements.140 Nursing Documentation Any consideration of the documentation of restraint thus involves budgetary costings of these items. Indeed. Accountability of the organisation The use of restraints can have serious legal consequences. grievance. articles. Practical issues in restraint policy documents Practical consideration must be given to a number of issues when preparing policy documents on restraint. and practical arguments for and against the use of restraint in aged-care nursing have been the subject of many important studies. • anti-discrimination. and appeal issues. and books. This chapter is essentially concerned with issues of documentation—not a full-scale analysis of the wider arguments for and against the use of restraint. charges of assault and battery might be brought (Wallace 1997). and • occupational health-and-safety issues. grievance. ethical.

procedures. NBWA 2004). certain risks should be recognised Furthermore. The second category of restraint documentation noted on page 138 referred to assessment documentation. the use of restraint has many implications in terms of residents’ rights and the duty of care of nurses. Such legislation usually includes provisions regarding infection control. risk assessment and management. and protocols on restraint. These include such rights as: • anti-discrimination rights. Before implementing any restraint. All of these topics must therefore be addressed ‘The rights of residents to take in policy documents on restraint. These rights should be recognised and included in the documentation on restraint policies. • grievance rights. In drawing up policies. 2. manual handling. and so on. use of chemicals. Assessments . accreditation and included in the documentation on restraint policies. Occupational health-and-safety issues Most jurisdictions have specific legislation with respect to workplace safety and matters of risk. and • appeal rights. agedcare facilities must therefore ensure that all relevant statutory and common law requirements are observed with respect to residents’ rights. These issues obviously have implications for any documentation on matters of restraint.141 Documenting Restraint issues. the use of protective equipment.’ standards and professional nursing bodies often require policy statements regarding the rights of residents to take certain risks (see. It is therefore incumbent upon each organisation to ensure that its documented policies are in accordance with all relevant protocols and guidelines. for example. These legal and ethical requirements differ from jurisdiction to jurisdiction.

employers.’ care. Written consent is a fundamental component of professional documentation. as applicable. • mini-mental examination. • communication assessment. Even if the aged-care facility does not insist on such a signature on the resident profile. Initially.142 Nursing Documentation a comprehensive documented assessment is required. Authorities are similar to consents. Consents and authorities . • depression-rating scales. a resident profile should be completed. The resident profile must be compiled from information given by the resident or his or her representative. page 114). The third category of restraint documentation noted on page 138 referred to consents and authorities. and the recipients of care in the event of any allegations of malpractice. and • assessment of risk of falls. • special senses appraisal. Such written consent provides legal protection to employees. • mobility and dexterity capabilities. it is mandatory that signed consent is obtained before any form of restraint is instituted (see below). For written consent to be valid it must conform with certain requirements. As noted in the discussion on the documentation of complementary therapies (Chapter 8. These additional assessments might include examination of: • behavioural patterns. • sleep patterns. but authorities are usually provided by a person other than the resident. These are listed in the Box on page 143. some organisations insist that the informant signs the profile as proof ‘It is mandatory that signed consent is obtained before any of his or input into the planning of form of restraint is instituted. Various statutory Acts contain 3. This directs the assessor to more specific assessments.

• informed. These criteria mean that the person who provides the written consent must be free to do so in an entirely voluntary fashion—with no suggestion of coercion.’ consent is valid only if all relevant information has been explicitly provided to the signatory. A copy should be given to the resident and/or representative.143 Documenting Restraint Requirements for valid consent For written consent to be valid it must conform with certain requirements. he or she must be informed of desired effects. This person must be provided with all relevant details of the proposed restraint. In particular. Depending on the local jurisdiction. The person must be legally entitled to provide the consent. Mental Health Acts. All authorities and consents should be signed. relationship to the resident). As noted in the Box ‘All authorities and consents should above. The policies of some organisations mandate that only certain senior staff members have . written authority or be signed. provisions regarding the rights and responsibilities of persons who can authorise treatment interventions on behalf of others—including restraint interventions. and • legal—that is. and dated. this person must meet all statutory requirements within the particular jurisdiction. and Adult Guardian Acts. Following these notations each signatory should print his or her name and status (for example. side-effects. witnessed. If the person giving consent is a representative of the resident. and any known risks or idiosyncratic reactions. such Acts might include Health Acts. The educational information that has been provided should be documented for the record. Attorney Acts. Such consent must be: • voluntary. and the original should be filed in the resident’s health record. the resident must be cognitively ‘intact’—and thus competent to give consent. If given by a resident. and dated. provided by a person who is legally entitled to provide it. witnessed.

these designated persons are responsible for ensuring that signatories are provided with all relevant information.’ in a double bed and feel insecure in a narrow single bed. specific incorporated into a resident’s care documentation is clearly essential. Even if these requests are made freely and spontaneously. . they have been used to sleeping they should still be documented. Care plans The introduction to this chapter (page 138) listed several categories of documentation relevant to restraint interventions.144 Nursing Documentation the authority to witness legal documents. The fourth category of restraint documentation referred ‘If restraint is incorporated into to care plans. Others … Even if these requests are prefer bedrails at night because made freely and spontaneously. these risks are compounded by inadequate observation and monitoring of restrained residents. If restraint is a resident’s care plan. an aged-care resident (or that person’s representative) might actually request that restraint be applied. If such a policy is in place. If the condition of a resident changes over time. In many cases. some residents feel more secure with a lap sash when ‘A resident might actually request that restraint be applied mobilising in a wheelchair. they should still be documented. There are many risks associated with the use of restraints. specific documentation is clearly essential. For example. Any such arrangements should be reviewed regularly and frequently. This is often due to limited staff numbers with resulting inadequate nurse/resident ratios. a consent that was obtained at admission might be no longer legally valid.’ plan. In some jurisdictions consent for restraint must be renewed every three months. Written authorities or consents must be reviewed regularly and frequently—with a view to upgrading and renewing them as appropriate. 4. In some instances.

Other documents that need to be completed and retained by the organisation include: • audit results related to the use of restraints. These include: • an authority to restrain form—with signatories. the resident was taken to the toilet. consent. the resident received a hand massage. dates.145 Documenting Restraint The care plan should include: • the type of restraint to be used. • how the restraint should be applied. 5. signed entries of administration. and • evaluative criteria. and review dates all being clearly noted. Apart from the nursing-care plan (see page 144). the resident was mobilised. and the results of any actions taken. and ‘close-out’ procedures taken. • the objectives of care. records of all effects. what actions were taken. • a restraint review form—with a record of the times when the restraint was applied and when it was released. • behavioural-assessment forms—with a clear description of the behaviour. and so on. and • any incident reports—noting the type of injury incurred. the resident had his or her clothes changed. • a record of any comfort activities undertaken—for example. outcomes. The Box on page 146 contains an example of a suitable care plan involving restraint. Other resident documents . • the duration of the restraint. education provision. • required observations and actions. • completed hazard-identification forms. actions taken. there are other essential documents to keep in the resident’s record with respect to restraint. the resident was offered or given fluids. • medication administration forms—prescriptions. the duration of the behaviour.

the lap belt should be released. Duration of restraint application As soon as Mrs A has been transported back to her chosen area following her shower. • Mrs A’s skin remains intact and not traumatised. cease the procedure. Evaluative criteria • Mrs A is comfortable and not distressed. cover her. • Observe Mrs A’s behaviour carefully. • Mrs A has her hygiene needs met. • The belt should not restrict circulation or access to the underlying skin. • Use the adjustment apparatus so that the belt fits snugly around Mrs A’s hips. observe the skin for any blanching or erythema. and talk to her until she calms down. • Mrs A is safe throughout the procedure. How the restraint should be applied • Once Mrs A is transferred into the shower chair. • be kept safe. Objectives of care Throughout her shower. Mrs A will: • remain seated • be kept comfortable. Required observations and actions • During the shower. Loosen the belt if either occurs. . the lap belt should be applied.146 Nursing Documentation Care plan—restraint Type of restraint to be used A lap belt will be used when Mrs A is being showered. If she becomes agitated or distressed.

Evaluation 7. Education The final category of restraint documentation noted on page 138 referred to education. progressive anecdotal entries in the resident’s notes on a ‘shift by shift’ basis constitute the most useful documentation. or planning future educational activities. The altered cognitive ability and mood swings of many of the residents makes objective assessment problematical. If behavioural changes or emotional stability are the goals of the interventions. An ethics committee can assist with documenting such issues as confidentiality of data. Education about restraint should be provided to staff. residents. Measurement tools might include physical signs. volunteers. and that this be properly witnessed. To measure the actual effectiveness of the use of restraint the assessor needs to refer to the resident-centred objectives and timeframes. research. the right to withdraw. and • audits of equipment safety and building safety. sharing of findings or results. It is essential to document evaluative data—whether these are being used for assessment of ‘It is essential to document clinical effectiveness. and their representatives. The sixth category of restraint documentation noted on page 138 referred to evaluation. and social interactions. If the organisation intends to conduct research it is imperative that participants sign a contract. psychological ‘Progressive anecdotal entries in the resident’s notes on a ‘shift by reactions. shift’ basis constitute the most These should be documented over useful documentation. .147 Documenting Restraint • risk assessments and risk analyses that have been conducted.’ a period of 3–7 days to minimise unintended bias in the data.’ benchmarking. and the purpose of the research project. effective evaluation of the use of restraints in the agedcare sector is often difficult to achieve. industry evaluative data. However. 6.

competency-based training. and so on. current practising certificates. and recognition of prior learning (RPL). • educational plan—a comprehensive educational program (including lesson plans). and the use of continuous restraint should always be questioned. education must be ‘needs driven’ in meeting the objective ‘gaps’ and requirements of the facility and its staff. . qualifications.148 Nursing Documentation Documentation of education with respect to the use of restraints should include: • needs analysis—a recently completed analysis of educational needs in the facility. and behavioural management techniques are far more appropriate than increasing the distress of already anxious residents by utilising restraints. To be effective. All ‘Education must be ‘needs credentials and competencies should be driven’ in meeting the objective properly documented and recognised ‘gaps’ and requirements of the with appropriate responsibility and facility and its staff. expenses. and must be properly evaluated. together with details of whether the participant attended when on duty or off duty. Residents have the right to be cared for in a dignified manner. • staff competence—records of staff members’ achievements. Conclusion Restraints (or ‘protective assistance devices’) should be used only as needed. and • in-service training—records of attendance at internal or external educational presentations.’ remuneration. When considering the possible use of restraint. restraint can be justified. nurses should ask themselves the following questions: • ‘Is this person in danger of self-harm?’ • ‘Is this person putting the safety of others at risk?’ If the answer to either question is ‘yes’. remuneration. Any educational program should incorporate the principles of adult learning.

such accurate ‘In law. documentation must be comprehensive and accurate as proof of the provision of quality care. . it didn’t happen. it didn’t happen’. Nurses should always be aware of the oftquoted legal axiom: ‘In law. the least restrictive form of restraint should be used. if it’s not written and comprehensive documentation is down. if it’s not written down. In the case of restraint.149 Documenting Restraint However.’ especially important. If legal action ensues. and the duration of its use should be restricted to the duration of the dangerous behaviour. these documents could well be presented in a court of law. In all aspects of aged-care nursing.


. Reporting and recording of incidents has many benefits.Chapter 11 Incident Reports Adrian Cross Introduction The reporting of incidents is a vitally important aspect of nursing documentation. • improved occupational health and safety for nurses. attention must also be a significant contribution to high standards of care for residents given to recording such reports in and improved occupational an organised fashion that allows health and safety for staff.’ for review and analysis of all incident reports. Proper incident reporting makes a significant contribution to the maintenance of high standards of care for residents and improved occupational health and safety for staff. • more effective management of inventories. accurate reporting and recording of incidents facilitates: • the promotion of a higher standard of care for residents. In particular. and • more efficient maintenance for aged-care facilities. In addition to reporting ‘Proper incident reporting makes incidents.

nurses owe a greater duty of care to the residents in their care. it is important to establish an understanding of the key terms that will be used in this chapter. administrative. or change of available or desired recreation. laundry. medical. Staff Apart from nurses. Common law duty of care Common law duty of care is the duty of care owed by any person to his or her fellow citizens.152 Nursing Documentation Before exploring this subject in greater detail. and • a policy—how an aged-care facility intends to achieve its mission and vision. Because they have received specific training. the term staff includes catering. Statutory legal requirements Statutory legal requirements are requirements of Acts of Parliament. These aims or intentions might be detailed in: • a mission statement—what an aged-care facility sets out to do in establishing the facility. Glossary of key terms Incident reports Incident reports include any reporting by nurses of specific incidents—such as falls. change of health status. (continued) . other ‘minor incidents’ (such as failing to come to meals) should be reported and documented. cleaning. Standard of care The standard of care is a written statement of the aims or intentions of an aged-care facility. and paramedical personnel. A glossary of such key terms is presented in the Box below. In addition to specific incidents. Residents Residents are the recipients of nursing care in an aged-care facility. • a vision statement—what an aged-care facility sees as needing to be done to fulfil its mission.

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Hazard A hazard is any situation that has the potential to cause harm to people or property. Occupational health and safety Occupational health and safety is the management of illness or injury associated with work activities. This is usually a statutory legal requirement. In some jurisdictions, occupational health and safety includes the health and safety of any people (not just workers) who might be affected by work activities at a workplace. Building and equipment items Building and equipment items include any parts of a building (such as door handles, wash basins, or floor coverings) and any items of equipment (such as furniture, resident-transfer aids, cooking appliances, washing machines, and so on).

Importance of incident reports
The reporting of incidents is an indication of the professional standards of an aged-care facility. Nurses should be attentive to what is happening in the facility, decide what needs to be reported, and pass on the details to ‘Nurses should be attentive to their colleagues. what is happening, decide what needs to be reported, and pass on Nursing in aged care is a the details to their colleagues.’ continuous activity. The reporting of incidents that are noticed by one nurse on one shift might have an impact on another nurse at a later time. To maintain continuity of care, incident reports are thus an important part of the handover procedure at a shift change. In some jurisdictions, the reporting of incidents by nurses is a statutory legal requirement. Even if there is no statutory requirement,

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the recording of incident reports is an indication of the discharge of the nurse’s duty of care. Nurses’ incident reports are also important for the updating of organisational records. To ensure that the reporting and recording of incidents is not impeded, the organisational procedures in aged-care facilities must make the reporting of incidents as straightforward as possible.

Deciding what to report
In all aspects of their professional lives, aged-care nurses are required to apply critical thinking in making decisions about priorities. Such critical thinking is also required in ‘If nurses are in doubt they should deciding what to report when adopt a general policy of reporting an incidents occur. Although some incident, rather than ignoring it.’ incidents are clearly more important than others, if nurses are in doubt they should adopt a general policy of reporting an incident, rather than ignoring it. Incidents of concern might relate to: • residents; • nurses; or • the aged-care facility itself.

In assessing incidents involving residents, nurses should be alert to issues that are of special concern to those in their care. These matters can be divided into: • lifestyle needs; • clinical needs; and • community needs. The Box on page 155 lists some of the major concerns under each of these headings.

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Residents’ concerns
In deciding what to report, nurses should be alert to issues that are of special concern to those in their care. Lifestyle needs Lifestyle needs include: • emotional support; • independence; • issues of privacy and confidentiality; • leisure interest and activities; • cultural and spiritual issues; • issues of choice and decision-making; and • issues of safety and security. Clinical needs Clinical needs include clinical care, individual nursing care, and other healthrelated care. This broad area includes such specific matters as: • medication management; • pain management; • nutrition and hydration; • continence management; • behavioural management; • assistance with mobility and dexterity; • skin, oral, and dental care; • assistance with sensory loss; • assistance with sleep loss; and • palliative care. Community needs Community needs include: • assistance with residents’ rights and responsibilities, access to personal information, and awareness of complaints procedures;

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• ongoing monitoring of support (following an initial or subsequent assessment); • care-plan changes; • referral arrangements; • social and financial independence; • privacy and dignity; • awareness of service’s procedures; and • awareness of access to advocacy.

In assessing incidents involving nurses, attention should be paid to the issues that are of special concern to nurses. These matters include: • regulatory compliance; • education and staff development; • planning and leadership; • human-resources management; • inventory and equipment; • information systems; and • external services.

Aged-care facilities
In assessing incidents involving aged-care facilities, attention should be paid to the issues that are of special concern to the facilities themselves. These matters include: • the living environment; • occupational health and safety; • fire, security, and emergency procedures;

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• infection control; and • hospitality services (catering, cleaning, laundry, shopping).

Arrangements for reporting
Arrangements for reporting incidents differ from facility to facility, but an easy way for nurses to note and report incidents is to keep a notebook with them at all times in which they can write down the details of any ‘An easy way for nurses to note and report incidents is to keep a incident or change that they notice in the course of their shifts. Critical notebook with them at all times.’ incidents must obviously be reported immediately, but the remainder of the notations require judgment in deciding what is to be recorded in clinical progress notes and/or incident reports. The organisational procedure for incident reporting must be simple. It is preferable to complete the report soon after the incident—and certainly by the end of the shift. In this way, the time, date, and details of the incident can be recorded and reported at the next handover.

Responsibility for incident reporting
General responsibilities
Aged-care facilities must make arrangements for dealing with the matters listed above. The responsibilities of the facilities lie mainly in the areas of safe practice and hazard control. The nurse’s professional ‘The nurse’s professional role is to monitor work practice and role is to monitor work practice environmental safety for themselves and environmental safety for and those in their care.’ themselves and those in their care. This involves nurses in being aware of the issues involved, being observant, and querying any matters that cause them concern. As part of this process, nurses should report and record hazards and incidents as appropriate.

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Statutory responsibilities
In most jurisdictions, there is a statutory legal requirement to report certain notifiable illnesses suffered by residents or staff members. Statutory legal requirements can also include reporting on any issues that involve fire safety and serious accidents.

Clinical issues
Any clinical change that is a possible indicator of other concerns—such as reduced fluid intake—should be noted and recorded. This provides other nurses with an opportunity to monitor the change and to respond appropriately if the concern becomes a significant problem. Such reports are an important part of handover arrangements, especially when a large number of nurses is involved, and reports are thus important in ensuring continuity of care for residents. Without this, nursing care can become ineffective, fragmented, and spasmodic.

Collating and analysing reports
Collating incident reports enables an organisation to review records and thus identify any trends in the occurrence of incidents. An individual report of an incident does not ‘Trends or clusters of incidents can be enable this to happen. Trends detected only if the individual reports or clusters of incidents can be are consolidated and organised.’ detected only if the individual reports are consolidated and organised. For example, a change in the incidence of skin rashes following a change of laundry detergent might be detected after reviewing several reports of such incidents.

Building or equipment maintenance
It is important to report incidents involving building or equipment maintenance. A failure to attend to maintenance requirements can mean that care is compromised if a particular piece of equipment required by nurses is unavailable or fails to function. For example, if resident-transfer aids are not properly maintained, an unsafe environment is created, which

159 Incident Reports

can result in injuries to nurses and residents. Nurses must therefore put a high priority on reporting equipment and maintenance needs. Consolidating such reports and updating organisational records enables maintenance to be managed in a planned fashion. Planned management of maintenance can significantly improve the standard of care delivered to residents.

Supplies and inventories
Inventories of supplies and specific purchases are arranged at an organisational level, but some nurses have specific responsibilities in this area as part of their duties. As with maintenance requirements, the way in which inventories and purchases are managed can have a significant effect on the standard of care delivered by the facility.

Occupational health and safety
Importance of ‘near misses’
Occupational health and safety (OHS) essentially involves detecting work-related hazards and assessing risks. Because the causes of accidents and incidents can be difficult to detect, ‘The so-called “safety lag” is the tendency for nothing to be done until accident-causation models someone becomes ill or injured.’ are used. These provide an indication of what to look for in investigating incidents and accidents, and give an indication of whether all the causes of accidents and incidents have been identified. Such models are also useful in proactively identifying hazards before any accidents or incidents have occurred. This reduces the socalled ‘safety lag’—which is the tendency for nothing to be done until someone becomes ill or injured. One such accident-causation model is called the ‘safety triangle’. This model aims to identify all causes regardless of whether they are part of any particular accident-causation sequence. In general, it has been found that for every serious injury associated with any given

1 (below). as illustrated in Figure 11.’ that are controlled. and 300 ‘near misses’. examining near misses is likely to promote effective control measures. In contrast to the usual response to serious accidents (which tends to emphasise only a small number of all the possible causes of accidents). If such an approach is adopted. 1 serious injury 1 10 minor injuries 10 30 non-injury incidents 30 300 near-miss incidents 300 Figure 11. medical aid. The safety triangle challenges organisations to adopt a ‘bottom–up’ preventative approach by responding to ‘near misses’. for ‘Examining near misses is likely to every 300 ‘near-miss’ incidents promote effective control measures. This can be expressed as a ‘triangle’. compensation.160 Nursing Documentation hazard there are 10 minor injuries. 10 minor injuries are controlled. and rehabilitation. accident reporting and investigation. 30 noninjury incidents can be avoided. . 30 non-injury incidents. 1 The safety triangle AUTHOR’S CREATION Most organisations respond to serious injuries with first aid. and 1 serious injury might be prevented.

the factors involved in producing an accident or incident can be divided into: . In addition. Sequence of events As noted above. see ‘Sequence of events’. this is clear evidence that a hazard exists in the workplace. and • to decide how the situation should be recorded for statistical purposes. As well as these primary factors. the chance of a similar accident occurring again will be reduced or eliminated. steps should be taken to facilitate retrieval of this information for subsequent analysis or research. the chance of a his or her level of experience. second-order (or contributory) factors include such matters as ‘If the circumstances that brought about the accident can be modified the age of the injured person. For more on primary and secondary factors. The second purpose of an investigation is to decide the way in which the situation should be recorded for statistical purposes.161 Incident Reports Investigating incidents Purposes of an investigation If an illness or injury does occur.’ that brought about the accident can be modified or eliminated. materials. similar accident occurring again will and so on. and equipment in the work system or environment. Any investigation has two prime purposes: • to determine the circumstances that brought about the illness or accident. If the circumstances be reduced or eliminated. below. Information obtained from investigating such situations can be used to prevent further illnesses or injuries. primary factors to be considered include people. or eliminated. It is important to ensure that any information is classified in a way that measures the consequence and the probability of the situation. In determining the circumstances that brought about the accident.

To prevent further accidents or incidents it is necessary to investigate the less-visible parts of the sequence. The Box on page 164 provides examples of the factors in the sequence of events illustrated in Figure 11. or death) and/or property (damage or loss). these factors combine to produce an incident. are causes. The focus must be on the earlier factors in the sequence—(i) primary causes (loss of control and basic causes) and (ii) secondary causes (immediate causes). the primary factors (a lack of control by management and basic causes) and secondary factors (immediate ‘The primary factors and causes) combine to precipitate a secondary factors combine to precipitate a “contact event”—the ‘contact event’—the incident or incident or accident that results in accident that results in harm to harm to people and/or property.162 Nursing Documentation • primary factors. The secondary factors are the immediate (or near) causes of the incident.2. As shown in Figure 11. Eliminating possible causes prevents the accidents and incidents occurring—thus diminishing or eliminating the resulting harm—and nurses have an important preventative role to play in this regard. Taken together. . and • basic or underlying causes.2 (page 163). and • secondary factors By convention. the primary factors contributing to an accident are furher subdivided into two groups: • a lack of control by management. The accident or incident might be visible—although it is surprising how varied the descriptions of an accident or incident can be. The harm or loss is the more ‘visible’ part of the above sequence. even if visible.’ people (injury. illness. Nurses have a responsibility to recognise and report these primary and secondary factors in aged-care facilities. However. it must be borne in mind that neither the harm nor the contact event.

loss Figure 11.2 Primary and secondary factors causing a contact event AUTHOR’S CREATION Conducting an investigation In investigating any incident.163 Incident Reports Primary factors Lack of control by management Basic causes + Secondary factors Immediate causes ↓ Contact event Accident or incident ↓ Harm Personal harm Injury. illness. death Property harm Damage. answers must be sought to the following questions: • When and where did the accident occur? • What happened and who was injured? • What were the contributing factors? .

inadequate warning systems. operating at an improper speed. or security.164 Nursing Documentation Examples in the sequence of events This Box lists some examples of factors in the sequence of events illustrated in Figure 11. failure to use personal protective clothing and equipment). fire and explosion hazards. Secondary factors Secondary factors (or immediate causes) can include: • unsafe acts (such as operating without authority. This harm or loss might apply to health. or injury. or abnormal wear and tear). output. decreased motivation. failure to warn others. defective tools and equipment. safety. quality. Basic causes can include: • ‘people factors’ (such as a lack of knowledge or skill. or • unsafe conditions (such as inadequate guards or protection. hazardous atmosphere. substandard housekeeping. excessive noise.2 (page 163). or • ‘workplace factors’ (such as inadequate work systems. dangerous substances. Primary factors Lack of control can include: • an inadequate OHS program. . congestion. unwanted event that causes harm. improper use of equipment. Harm Harm includes harm to people and harm to property. health deficits). inadequate design or maintenance. inadequate purchasing standards. • inadequate OHS standards. or • failure to observe established OHS procedures. or inadequate illumination). Contact events A contact event is an unplanned. illness.

Government inspectors.165 Incident Reports • What was the sequence of events? • How can a similar accident be prevented from occurring again? Care must be taken not to disturb the accident scene—especially if the resulting harm is serious. most statutory requirements have the following objectives: . However. • avoid rushing through the interview. sketches. Eye-witness accounts must be carefully documented. Relevant persons should be interviewed—preferably in a quiet and private setting. barriers. the interviewer should: • reassure the interviewee. When conducting interviews. • state that the interviewer is seeking causes. in general. or staff. and recordings at the scene. are also important. Statutory requirements Statutory legal requirements with respect to reporting accidents and incidents vary among jurisdictions. and • close the interview by thanking the interviewee. In dangerous situations. Safety at the accident scene is also important. even if they did not actually see the event. not attempting to apportion blame. • use open questions that prompt the interviewee to give explanations and descriptions (rather than ‘yes or no’ answers). This information should be carefully documented because it might be called as evidence in legal proceedings. The accounts of other people who were present at the scene. It also is important to interview the ill or injured person. police. photographs. investigators should take care not to involve more people than are necessary. or other authorities might require access to the undisturbed site. • take careful notes. • read the record of the interview back to the interviewee. Interviews should be conducted as soon as possible after the accident or incident. The site might have to be protected with tape. It is important to take measurements.

Building.’ and equipment items that require attention. • to identify appropriate preventative strategies. There must be proper arrangements for the making of maintenance requests. The incidents to be reported include matters that concern residents. • to provide a comprehensive set of data for the management of OHS in workplaces. for filing ‘There must be proper arrangements non-conformance reports. plant and equipment is serviced or replaced before it breaks down. • apply critical thinking in deciding which events are significant. because this can significantly compromise nursing care. . and for for recording nurses’ documentation recording nurses’ documentation of incidents relating to building of building and equipment items that require attention. equipment. matters that concern nurses.166 Nursing Documentation • to provide information on the nature and extent of illnesses and injuries at workplaces. Organisational arrangements are required if a proactive system is to be established. a proactive approach is preferable. and inventories and purchases. and purchases Many aged-care facilities take a reactive approach to questions of plant maintenance. The reporting of incidents requires nurses to: • be attentive to what is happening. and • to provide data to monitor the effectiveness of preventative strategies. Under such a system. • to facilitate efficient allocation of resources. inventories. These include OHS issues. Conclusion Incident reports are an important part of nursing documentation. However. building and equipment matters. and • document accurately to ensure that details are communicated to their colleagues. and matters that concern aged-care facilities.

The reporting and recording of incidents is an important aspect of optimising the safety and wellbeing of residents and staff alike.167 Incident Reports Organisational arrangements should be in place for the recording and review of incident reports. . In some jurisdictions there are statutory legal requirements for the reporting and recording of incidents.


To place value or worth on something or someone involves making a personal judgment that can be fraught with problems. traverses ‘throughput’. Introduction . and concludes with ‘output’. the most important phase of care provision. or principle. all future care actions are in jeopardy of being unsuitable. Through evaluation. from the Latin valere (‘be worthy’). Evaluation is. the most important phase of care provision. all aspects of care can be deemed as being either ‘effective and appropriate’ or ‘ineffective and inappropriate’.’ potential problems of subjective judgment. arguably. Evaluative criteria are measurement parameters that are based upon an accepted rule. or even potentially hazardous. If the documentary evidence of evaluation is inadequate.Chapter 12 Documenting Evaluative Criteria Sue Forster The English word ‘evaluation’ is derived from the French evaluer (meaning ‘to value’). standard. Evaluation measures care across a continuum that commences with ‘input’. an evaluator should use objective evaluative criteria. To minimise or negate these ‘Evaluation is. arguably. All of these phases of care need to be clearly documented and evaluated.

reduced infections. that increasing fluid intake reduces urinary stasis (and thus decreases the incidence of infections). Examples of criterion-referenced evaluations include: • a reduction in diastolic blood pressure following rest in bed.170 Nursing Documentation Evaluation methodologies and evaluative criteria should be utilised whenever nurses are documenting their provision of care. The criteria in the above examples include reduced blood pressure. reduced falls. Criterion-referenced vs norm-referenced measurements Criterion-referenced measurement A criterion-referenced measurement is made when a decisive measurable factor is used to ascertain whether the care provided a particular outcome. • subjective measurements vs objective measurements. 1. and that this measurement must be based upon an accepted rule. and • increased participation in activities following implementation of a behavioural-management program. • a reduction in the number of falls following supervised mobilisation and the use of a walking aid. • formative techniques vs summative techniques. and that application . • clinical indicators. and increased participation—which can all be measured. that assistance with mobilisation and the use of walking aids prevents falls. • reliability and validity. The accepted rules in the above examples are that resting reduces cardiac output. Some concepts associated with evaluation include: • criterion-referenced vs norm-referenced measurements. Each of these is discussed below. and • continuity. • a reduction (or absence) of urinary tract infections following ingestion of 2 litres of fluid per 24 hours. It is important to note that the criterion or outcome must be measurable.

All criteria must be documented. • subjective measurements vs objective measurements. Concepts in evaluation Some concepts associated with evaluation include: • criterion-referenced vs norm-referenced measurements. A record of baseline observations is insufficient for a criterion-referenced evaluation—because a ‘oneoff’ event does not prove or disprove an hypothesis. measurement cannot take place.171 Documenting Evaluative Criteria of appropriate behaviour-modification techniques increases a person’s interactions with the environment. This is because the standard shifts in accordance with the performance of the group as a whole. If there are no historical data. A discussion of these concepts forms the framework for this chapter. historical data ‘A “one-off” event does not prove or (including chronological and disprove an hypothesis … historical data must be documented. Norm-referenced measurements A norm-referenced measurement is made when the outcomes are indexed against the results of a group. and • continuity. There is no absolute standard in norm-referenced measurement. Norm-referenced measurements are based upon the assumption that the concept being measured is distributed along a normal bell-shaped curve. It is inherently biased. • formative techniques vs summative techniques. Before any significance can be placed upon the findings. Norm-referenced evaluation includes ranking the members of a group in order of their placement within the group. If new residents join the group.’ regular measurements) must be documented. • clinical indicators. any statements made about the standard are subject to change. • reliability and validity. .

’ are most useful for research purposes and for making decisions about staffing the organisation. The findings of purposes and for making decisions norm-referenced evaluations about staffing the organisation.’ modify care. Formative vs summative techniques Formative evaluation Formative evaluation is based upon a process of informing. Formative evaluation is thus a continuous. Mr B is the least disruptive. 2. this can be very valuable for strategic planning purposes. any statements made about the person might have to be changed—because the overall group norm changes. The first stage of formative evaluation involves documenting daily anecdotes. It is a valuable tool for all to continue. It should be noted that every one of the above statements refers to how the person in question compares with everyone else.172 Nursing Documentation Examples of norm-referenced evaluations include: • Mrs A calls out more than any other resident. If new residents join the group. and corrective method. The final stage of each analysis is re-evaluation. It is progressive and assists with planning or redesigning care provision. It is a valuable tool for all care planners and care providers. and corrective data—and then decide whether method. The resulting documentation serves many purposes—both organisationally and for each individual resident. diagnostic. events. treatment regimens. • Mrs C falls more often than any other resident. The next stage is to analyse the ‘Formative evaluation is a continuous. and • Miss D requires more nursing-care time than anyone else. Norm-referenced evaluations therefore do not ‘The findings of norm-referenced provide precise individual evaluations are most useful for research information. diagnostic. and investigative findings in the resident’s health records. or care planners and care providers. . discontinue. If performed carefully over a period of time.

Other assessors might provide other explanations for the residents’ behaviours. finite.’ must start a new process if care is to be continued. Once a summary of an event ‘Summative evaluation is has been documented. and descriptive. It is a summary of the outcomes of any event. and descriptive. Examples of summative statements can include certificates (including death certificates). assessors must be alert to the fact that great caution is required when acting upon the gathered data. pathology results. . the statements cannot be classified as statements of established fact. Examples of subjective evaluations include: • Miss A is unnecessarily requesting nursing attention. 3. The findings are therefore unpredictable—and the reliability and validity of the results are questionable. and • Mr C does not participate in communal activities because he dislikes the other residents in the group. • Mrs B has had a bad day that resulted from her being late for breakfast. Each person’s subjective evaluation is likely to be different from those of others.173 Documenting Evaluative Criteria Summative evaluation Summative evaluation literally means ‘at the end’. even if the opinions come from experienced observers. opinions are stated. discharge plans. These opinions represent the writer’s perception of the event—based on the observer’s experience. Subjective measurements vs objective measurements Subjective evaluation Subjective evaluation is based on opinion—with few if any objective criteria used. However. Summative evaluation can best be described as terminal. In these examples. This is not to say that subjective evaluation is of little or no use. the assessor terminal. finite. and radiological reports. However.

It is best to avoid such words. For example. It is better to describe the actual events as objectively as possible—and leave value judgments to the reader. and emotions of residents. the use of subjective data is unavoidable when documenting the behaviour. suicidal ideation. In each case.174 Nursing Documentation Despite these limitations. it is often appropriate to write down exactly what was said by the resident. is often appropriate to write down exactly what was The results of such documentation said by the resident.’ can prove to be of significant value.1 (page 175) provides examples of actual events and possible value judgments. it is also possible that there are other valid explanations for the events as described. mood. Table 12. In documenting subjective opinions. • ‘non-compliant’. it can mean that the resident is unfairly labelled as being ‘aggressive’ or ‘uncooperative’— and such labels can affect the future care of the resident by adversely influencing the attitudes of other carers. all ‘To decrease subjective bias. • ‘refused’. If so. analysis of verbatim conversations might lead staff to recognise that a resident is experiencing hallucinations. However. making repeated value judgments can mean that readers interpret the use of value-judgement words as a reflection of the underlying biased beliefs of the writer. . Making value judgments in documentation can reflect adversely on both the resident and the nurse. or delirium. nurses should be aware that some words are ‘emotionally laden’. Such residents can be denied their legitimate rights to contribute to decision-making about their care. For the nurse. it direct quotations should be placed in quotation marks (‘inverted commas’). To decrease subjective bias. Examples include: • ‘uncooperative’. the value judgment might be correct. and • ‘demanding’. delusions. For the resident. • ‘aggressive’. depression.

respirations. grabbing. reliable. refused Aggressive Demanding In summary. • Miss C has lost 15 kilograms in weight over the preceding 12 months. valid. Whoever the assessor is.175 Documenting Evaluative Criteria Table 12. chooses not to do something. wishes not to do something Biting. In the above examples. Examples of objective evaluations include: • Mrs A walked a distance of 60 metres this afternoon. To make comparisons or demonstrate contrasting results it is crucial that all data are documented. he or she should produce the same results. professional evaluation is better served if nurses describe the actual events—and leave the value judgments to others. and blood pressure) have all been within the normal range over the past seven days. and • Mrs D sustained a skin tear on her left leg measuring 3 centimetres in length. asking for assistance every 5–10 minutes. This allows trends and deviations to be readily recognised and acted upon. swearing Repeating requests. pulse. and quantitative. actual measurements preclude variance in results. Some facilities have special observation forms that include graphs with upper and lower acceptable limits clearly marked. Objective evaluation Objective evaluation is criterion-referenced. non-compliant. . yelling out until attended Possible value judgment Uncooperative. Anyone who conducts an objective evaluation should produce the same results as anyone else using the same tool. • Mr B’s vital signs (temperature. hitting.1 Actual events and possible value judgments AUTHOR’S CREATION Actual events Declines to do something.

but it should be as small as possible. it is unreliable to use a variety of sphygmomanometers (manual and electronic) to measure blood pressure. They should be stable over a period of time and internally consistent. For example. Using the same piece of equipment each time increases reliability. To determine the validity of an evaluative tool. Similarly. weight scales should be tested to ensure that they are giving valid weight results. . In simple terms: • reliability tests the stability of a measurement. To increase a tool’s reliability. the tool needs to be clinically tested. The clinical tests should be documented and the variances taken into account when analysing the gathered data. Reliability and validity All evaluations should be both reliable and valid.176 Nursing Documentation 4.Reliability and validity Reliability and validity are different concepts. it is unreliable to use a variety of scales to establish a resident’s weight gain. Reliability A reliable evaluative tool should perform identically from day to day— irrespective of who is using it. They should also be recorded and interpreted in a manner that ensures that different assessors would agree with the results. In any evaluative tool there is always some error of measurement present. and sphygmomanometers (manual and electronic) should be tested to ensure that they are giving accurate blood pressure results. whereas • validity tests whether an evaluative tool measures what it is supposed to measure. For example. an evaluator should therefore take into account the variations in the characteristics being measured. but should exclude unrelated factors as much as possible. Validity As noted above. validity tests whether an evaluative tool measures what it is supposed to measure.

• pulse and respiratory rates. If the objective of accurate evaluation is to be achieved.’ are not so well defined or obvious. • pain assessments. The evaluator should select the evaluative . or principle. standard. and • sensory assessments. the application of evaluative individual results above. placing evaluation is to be achieved. Examples of clinical indicators include: • temperature recordings. Some clinical data are easier to measure than others. Clinical indicators Clinical indicators are virtually the same as evaluative criteria—in that both are measurement parameters that are based upon an accepted rule. • blood-glucose levels. The use of such data can compromise the reliability and validity of an evaluation tool. • biochemistry results. If a normal ‘If the objective of accurate range is universally accepted. below.177 Documenting Evaluative Criteria 5. • blood-pressure recordings. • psychometric evaluations. The selection of the appropriate evaluative criteria depends upon what is being evaluated. some clinical data statements should be avoided. The use of nebulous or non-definitive statements should be avoided. • elimination recordings. Utilising clearcut clinical indicators or evaluative criteria limits the potential corruption of results. • nutritional and hydration assessments. the application of evaluative criteria is mandatory. • wound assessments. or in criteria is mandatory … that normal range is a straightforward nebulous or non-definitive matter. • urinalysis. However. • behavioural assessments.

. Table 12.2 (below) provides examples of two resident-centred objectives with some applicable evaluative criteria. relatives. the objective might be that the resident will be comfortable. These criteria might include: • that the resident is clean and dry. The evaluative criteria should therefore measure the comfort level of the resident. and • that the resident is interacting happily with staff. Table 12. • that the perineal area is not red or excoriated. • that no pruritus is noted. For example. and other residents.178 Nursing Documentation criteria that best measure the outcome nominated in the resident-centred objectives. • that the resident is not trying to disrobe.2 Resident-centred criteria and evaluative criteria AUTHOR’S CREATION Resident-centred objective Miss A will be pain free Evaluative criteria Miss A states she is free of pain Pulse and blood pressure within normal parameters Absence of grimacing or guarding Posture relaxed Analgesics not required Mobilising without restriction Weight for height within normal range Healthy skin Skin turgor and mucous membranes normal Eyes not sunken Ingesting a well-balanced diet and completing her meals Fluid balance within normal range and urinalysis normal Bowel motions and patterns normal Biochemistry results normal Mrs B will be well nourished and achieve optmal hydration Evaluative criteria can be readily selected by answering the question: ‘Why was the objective formulated?’ The answer should be that the objective was formulated on the basis that certain evaluative criteria exist for measuring it. if a resident is assessed as being incontinent of urine.

This might. Figure 12. at first. 6. Assessments Evaluation Analysis Implementation Objectives Plan Figure 12.1 The cyclical nature of nursing care AUTHOR’S CREATION All aspects of care need to be clearly documented. . a model can help to explain the statement that evaluation and assessment are ‘synonymous’. Documentation of this cyclical process prevents previously trialled and ineffective actions being repeated. new actions need to be implemented. seem to be a surprising statement—because assessment is usually perceived to be an early stage in the nursing process. whereas evaluation is perceived as being a late stage in the process. The model clearly demonstrates the cyclical process of nursing care.2 (page 180) shows how this is documented on the cyclical model. However. or resident-centred objective. and the results need to be evaluated. the plan needs to be adjusted. Continuous process Evaluation is a process that is synonymous with the assessment process. It should not be necessary to change the initial assessment.179 Documenting Evaluative Criteria All evaluative criteria should be clearly documented and analysed to ensure that future planning and actions are expedient and appropriate. If the objective has not been met. analysis.

’ planning phase. and effective care is reliant upon accurate evaluation. Care plans should evolve from the analyses. Because it is not always possible for all team ‘Meticulous documentation is the members to be present during the linchpin of providing quality care. Meticulous documentation is the linchpin of providing quality care. record mobility activities.180 Nursing Documentation Mr B has not defaecated for 7 days Assessments Mr B had his bowels open and his normal pattern of every 2nd day has been re-established Evaluation Analysis Mr B is constipated Same as plan including: record fluid intake. precise and explicit documentation is therefore essential to ensure that accurate analysis is achieved. . record bowel actions Implementation Plan Offer 120 mL pear juice daily Extra serve of roughage with each meal Offer 200 mL fluid per hour Walk 60 m before and after each meal Objectives Mr B will evacuate his bowels and have his normal bowel patterns re-established Figure 12.2 Example of the cyclical nature of nursing care AUTHOR’S CREATION Conclusion The process of evaluation should be the responsibility of the members of the multidisciplinary team who provide the resident’s care. record food intake.

organisational survival depends upon effective HRM strategies being documented and enacted. • equal opportunity in employment. More than valuable resource. • anti-discrimination. All aged-care facilities should therefore have documented HRM policies. • occupational health and safety. This has been made even more evident by the decreasing ‘Human resources represent an organisation’s most availability of trained staff.Chapter 13 Documenting Staff Issues Sue Forster Introduction Issues relating to staff come under the umbrella of human-resource management (HRM). HRM strategies evolved from the realisation that human resources—staff members—represent an organisation’s most valuable resource. These should include policies on: • selection and recruiting.’ ever before. • affirmative action. .

• • • • 1. Many professionally designed documents—both hardcopy and electronic—are readily available for purchase through suppliers. • staff performance appraisals. The results of this job analysis should be reflected . complaints (internal and external). However. Once purchased. Each of these is discussed below. the first task is to conduct a job analysis. • staff attrition. and discipline. • disciplinary processes. These procedures include: • staff selection. these documents need to be individualised for the organisation. and definitive. and definitive. it is important to note that modern documentation extends beyond the recording of information on paper. Contemporary documentation also ‘Ambiguity and misinterpretation includes the electronic recording of should be minimised by ensuring data. Such electronic documentation that all documentation is should follow the same principles as specific.182 Nursing Documentation social justice. • staff retention. accurate. Each HRM policy should be accompanied by explicit procedural documents. accurate. before proceeding to examine these subjects in more detail. Purchasing and adapting such documents is both time-effective and costeffective. It is essential that ambiguity and misinterpretation should be minimised by ensuring that all documentation is specific.’ traditional hardcopy documentation. performance appraisal. and • credentialling. Staff selection Once it has been decided to fill a position on staff.

and an effective advertisement is a valuable marketing tool. • staff performance appraisals. Advertisements should reflect the desired image of the organisation. Advertisements should include the following documentation: • the vacant position. • a description of the organisation. Then.183 Documenting Staff Issues Framework of the chapter Each HRM policy should be accompanied by explicit procedural documents. in the position description and duty statement that describe the vacant position. • staff attrition. These procedures include: • staff selection. external advertisements should be posted in the employment section of newspapers. • staff retention. key selection criteria can be nominated. . its level. A discussion of these concepts forms the framework for this chapter. and in industry-specific journals. To attract a wider range of applicants. • the key selection criteria (KSC). desired image of the organisation. The next step in the process ‘Advertisements should reflect the is to advertise the vacancy. and • the address of the organisation. • disciplinary processes. and its reference number. and • credentialling. Internal advertisements ensure that staff members are aware of career opportunities within their own organisation. on the Internet. once the position description has been formulated.’ internally and posted externally. and an effective advertisement is Advertisements should be displayed a valuable marketing tool. • the name of the contact person for enquiries. • the closing date.

in the case of any appeals. and they should be provided with a choice of interview dates and times. . They should be notified that their referees will be contacted. All candidates should receive a letter relating to their application. All interested people who apply or enquire should receive an information package. Consensus of the panel determines the successful applicant. and • relevant time guidelines for the selection process. • a list of the KSC. The information package should include the following documentation: • a letter acknowledging their enquiry. Successful applicants should receive a list of possible interview questions—based upon the KSC. Ideally a properly constituted selection committee should perform these processes—so that. the decision-making process withstands public scrutiny. the process of culling and short-listing candidates is undertaken.184 Nursing Documentation Inclusion of remuneration details is optional. Structured interviews give candidates an equal opportunity to expand upon the information provided in their application. it is essential that referees’ reports are obtained and included in the consensus process. Once formal applications have been received. and it is therefore prudent to document every aspect of this stage. The letter informs the candidate: • that he or she has been short-listed (and the proposed interview date). • the organisation’s handbook. Ideally a panel should conduct the interviews. Unsuccessful applicants should receive a brief explanation of why they were not successful. To ensure that selection is just. or • that he or she has been unsuccessful at this point in time. • a copy of the full position description. and each member of the panel should individually record his or her scores on the responses provided by each candidate. In most jurisdictions there are strict requirements relating to industrial-relations legislation.

If the position involves . Because selection is a two-way process. the successful applicant should be sent a letter of offer of appointment.’ for the time period stipulated in the local jurisdiction. it ‘It is essential to keep all documents related to the selection process for is essential to keep all documents the time period stipulated in the related to the selection process local jurisdiction. Applicants who feel aggrieved after receiving such feedback should be given details of the appeal process. In case of an appeal.185 Documenting Staff Issues Documentation in staff selection This portion of the text discusses the documents that are required in a staff-selection process. These include: Preparation • job analysis • position description • duty statement • key selection criteria Seeking applicants • advertisements • information package Short-listing and selection process • letters to candidates (successful and unsuccessful) • accurate (and retained) records of selection committee After selection • letters to candidates (successful and unsuccessful) • a report of the selection process (if requested) • details of available appeal process (if requested) • letter of offer of appointment • employment contract • acceptance of conditions of employment in writing A report should be provided to any applicant who requests one.

authorised. The methodologies for staff retention can be included in the organisation’s employee assistance program (EAP). long-service ‘The documentation associated leave. All of these methodologies should be documented in the organisation’s handbook. The handbook reflects the desired image of the organisation. Temporary reduction of personnel includes absenteeism related to holiday breaks. The documentation associated with an organisation’s attrition rates is essential for strategic planning and budget projections. and a well-designed and professionally produced handbook is a valuable marketing tool. retention of staff members is essential for organisational survival. It is essential to document these costings in the organisation’s annual budget. The applicant should be asked to accept the conditions of employment in writing.186 Nursing Documentation the signing of an employment contract. 3. Some of these methodologies are shown in Table 13.1 (page 187). Staff retention With a worldwide shortage of trained staff. retirement. Attrition statistics . and study leave. Although retention of staff can be expensive for the organisation in terms of money and effort. Some reasons planning and budget projections. a copy of this contract document should be sent with this letter. Some managers include a temporary reduction in personnel in this concept. Staff attrition The term ‘attrition’ refers to reduction in personnel—through resignation. the costs are offset by the even greater costs of staff attrition. and expected. or to decline the offer in writing. The successful applicant should be advised to read the documents carefully. The organisation’s strategies for staff retention should therefore be clearly and unambiguously documented. sick leave. 2.’ for absenteeism are predictable. leave without with an organisation’s attrition rates is essential for strategic pay. maternity leave. or death.

Generally.1 Methodologies for retaining staff AUTHOR’S PRESENTATION Methodology Effective communications Features Education Feedback Performance appraisals Non-discrimination Counselling Psychological support services Negotiating work times and hours Job sharing Work contracts Teamwork Equity Consensus in decision-making Reduction in hierarchies Delegation Empowerment Accountability Responsibility Support mechanisms Induction/orientation In-service Traineeships Upgrading qualifications Financial support On-site provision Financial assistance Career paths Promotion Bonuses Flexible rostering systems Participatory management Education Childcare facilities Incentive programs can be compared with those in similar organisations for benchmarking purposes. rather than attend work. . high attrition rates indicate that the morale of the organisation is low.187 Documenting Staff Issues Table 13. Such high rates indicate that staff would prefer not to be paid.

All of the above documents should be filed in the person’s personnel record. • internal or external provision. carefully documented. and professional development plans. . page 173). the results can be utilised to implement measures to reduce attrition.188 Nursing Documentation Attrition rates are a summative evaluation (see Chapter 12. The education records should include: • attendance. • mandatory and compulsory requirements. page 172). Furthermore. analysed. to prevent the loss of personnel. they do little. Such a formative evaluation might be in the form of a staff-satisfaction survey. some regulatory bodies require evidence that unresolved issues or unmet expectations are being addressed. if a formative evaluation of the organisation is conducted (see Chapter 12. Staff performance appraisals Performance appraisals are evaluative tools used to measure an individual’s functioning within the organisation. a needs analysis. The process of conducting staff appraisals includes examination of the person’s education records. This should be stored in a secure area. These surveys should be conducted regularly and frequently. Most accreditation bodies state that regular staff reviews should be conducted and documented. and acted upon. in themselves. and which set out what he or she is expected to do in the role. Although they are of value to the organisation. • achievement. preventive actions to decrease attrition should be documented in the employee-assistance program (EAP). and access should be limited to authorised persons. Some organisations have extended these appraisals to include subjective data. 4. and • any contractual arrangements. anonymity should be assured. Once the analysis is available. These tools should be based upon the key selection criteria—which served as the blueprint for appointment of the staff member. However. To ensure valid results.

• a record of consent and agent representation. • a description of the issue. and these can be treated as valid if rigorous documentation of all relevant events is not available. • a written complaint. • a copy of the letter sent to the staff member being disciplined. and this is not the place to explore this complex subject in any detail. • witness statements. insofar as documentation of discipline is concerned. wrongful .189 Documenting Staff Issues 5. second. It has often been said that: ‘In law. Most industrial-relations legislation requires that the activities reflect a process referred to as ‘due process’. • any written responses to the matter being dealt with. Documentation includes: • a copy of the related policies and procedures. • transcripts of interviews conducted. if it’s not written down it didn’t ‘Detailed documentation of happen’. and final). Other issues that can occur in disciplinary procedures include discrimination and marginalising of individuals. • an investigation report. Disciplinary processes Rigorous documentation is mandatory when conducting disciplinary activities. Mischievous and vexatious complaints do occur. Disciplining a staff member is an exceedingly difficult task.’ is essential if this oft-quoted legal criterion is to be met. Detailed documentation of each stage of the disciplinary each stage of the disciplinary process process is essential. • a complete set of the employee’s personnel records. • full education records. rigour is essential. • copies of warnings undertaken (first. and • the outcome. However. • progress reports.

All of these can give rise to legal actions—and accurate documentation of all disciplinary procedures is therefore essential.190 Nursing Documentation dismissal. • educational records. and discriminatory behaviour. • a policy on recognition of prior learning (RPL). nurses’ registration boards. diplomas. A list of the documentation required for credentialling is shown in the Box below. Awarding a credential indicates to others that the recipient is competent in the subject. Documentation for credentialling The documents that are required for staff credentialling include: • the organisation’s accreditation certification with the relevant authority. • competency-based assessment tools. • a signed education contract/agreement. qualification certificates. • results of evaluation. educational institutions. • a full copy of the educational program being conducted. Some health facilities are registered training providers and are authorised to award certificates that are nationally recognised. Indiscriminate provision of awards can lead to dire consequences—including prosecution of signatories. registered training authorities. Credentialling An authorised body usually awards credentials. and degrees. • statements of attendance and achievement. An assessor should therefore not certify that a staff member is competent unless the assessor is absolutely sure that the person has demonstrated proficiency. . and • grievance and appeals policies. • a list of resources (personnel and material). and universities. 6. These bodies include schools.

performance livelihoods of the most important appraisals. validation of qualifications can be checked with the relevant registration authority.’ and credentialling. Meticulous documentation of staffing issues is a vital management responsibility because it directly affects the professional careers and personal livelihoods of the most important resources that an aged-care facility possesses—its valuable staff. documented HRM strategies in place. and must take account of all relevant statutory requirements. . As with all documentation. these should also be sighted and scrutinised. If there is any doubt. these policies and procedures must be recorded with care and accuracy. resources that an aged-care facility possesses—its valuable staff. It is essential to have policies ‘Meticulous documentation of and procedures in place on such staffing issues directly affects the vital subjects as staff selection. disciplinary processes. If annual certificates are required to practise. Conclusion Human-resource management (HRM) has become increasingly important in the context of the worldwide shortage of trained staff. All original qualification documents should be sighted and scrutinised for inaccuracies. Aged-care facilities must therefore ensure that they have effective.191 Documenting Staff Issues Another documentation issue to be addressed with respect to credentialling is the currency and validity of the certifying document. attrition. professional careers and personal retention.


the suggestions in this chapter will help nurses to design forms that best suit their purposes. Familiarity encourages compliance. but before designing a completely new form nurses should consider whether they are able to adapt an existing one. .Chapter 14 Effective Design for Documentation John Collins Introduction This chapter offers practical advice on the design of effective forms for nursing documentation. for future reference. Well-designed forms are easier to use. There are commercially designed forms for aged-care facilities. well-designed forms: • convey a lot of information among people quickly and easily. • record. The purpose of forms Why do nurses need forms? Among other benefits. what nurses have done. and if staff members are familiar with a form. • satisfy legal requirements. they are more likely to use it properly. and • give nurses more time to care for residents. and nurses should investigate whether these suit their purposes without alteration. If not.

Grade The paper that is chosen for a form depends on how often the form is going to be handled. Heavier paper can cause problems with smaller non-commercial photocopiers.194 Nursing Documentation The more time spent in designing a form. A simple rule to follow is that ordinary photocopy paper (known technically as 80 gsm. the more effective it will be. If the available photocopy facilities cannot use 90 gsm paper. Table 14. it might be necessary to use commercial printers. the less time will be spent in filling it out. or grams per square metre) is sufficiently strong for thirty normal ‘handlings’. If the form is likely to be handled more often than this. This is likely to entail increased costs in printing and storage. and • the size of paper to be used.1 Standard paper sizes AUTHOR’S PRESENTATION Name A3 A4 A5 Dimensions 297 mm x 420 mm 297 mm x 210 mm 297 mm x 148 mm . standard paper sizes should be used. a stronger paper (such as 90 gsm paper) is needed.1 (below). Equipment Paper Decisions need to be made on: • the grade of paper to be used. and the easier it will be for others to understand and use the information. Size To keep costs down. The dimensions of some commonly used paper sizes from the ISO ‘A series’ are shown in Table 14.

195 Effective Design for Documentation All of these paper sizes can be used in the normal ‘upright’ position (also known as ‘portrait’) or ‘sideways’ (also known as ‘landscape’). Most clipboards. 210 mm 297 mm 297 mm 210 mm Portrait Landscape Figure 14. A3 paper can be used. Using A4 as an example.2 (page 196).3 (page 196). If the files are likely to be stored in ring binders or punched files. . In addition to being cheaper.1 (below). and paper punches are designed to take these sizes. as shown in Figure 14. as shown in Figure 14. standard paper sizes are also more convenient. Care must be taken to ensure that the writing on the form is not obscured by holes or clips.1 A4 paper in portrait and landscape AUTHOR’S PRESENTATION If the information to be included on the form will not fit on one A4 sheet. the information can be spread over the front and back of a folded A3 sheet. this is shown in Figure 14. This gives the equivalent of four portrait A4 pages. A landscape A3 is the equivalent of two portrait A4 sheets placed by side by side. folders. the writing on the form should allow for this. Alternatively.

196 Nursing Documentation 420 mm 297 mm 210 mm Figure 14.2 Two portrait A4 making one landscape A3 AUTHOR’S PRESENTATION 210 mm 210 mm 210 mm 297 mm 297 mm A3 landscape 210 mm A3 folded making four portrait A4 Figure 14.3 One folded landscape A3 makes four portrait A4 AUTHOR’S PRESENTATION .

colours. 1. Identification In a health service in which many different forms are used. and logos are probably best left to a professional designer using advanced software. colour of the paper.197 Effective Design for Documentation Computer software Adequate forms for most nursing purposes can be created using common word-processing software. . lines. and • seek information logically. see page 199. Very complicated forms that involve boxes. care should be taken to ensure uniformity with other forms that are already in use. the name of the organisation should appear on the ‘Care should be taken to ensure uniformity with other forms form—using the same typeface that are already in use. the ‘cut-and-paste’ function of a wordprocessing program can be used to add the logo to a new form. or other colour-coding. and to arrange information in tables as appropriate. If the organisation has a logo. (For more on typefaces.) It is best to have a form that is easily recognised by its shape. Such programs allow users to choose various typefaces and point sizes. • be presented in a fashion that is easy to read and easy to complete.’ used on other documents. Principles of effective form design A well-designed form should: • be easily identifiable. symbols. These features are discussed in more detail below. • state its purpose. If this is not possible. • have a clearly recognisable title. • have a clear layout that leaves enough room for written entries to be made clearly and easily.

If the form is regarded as yet another bureaucratic interference.198 Nursing Documentation Principles of effective form design A well-designed form should: • be easily identifiable. the nature of the abbreviation. 2. information required. • state its purpose. The form should carry both its full title and its ‘The title should tell readers why the form is important. an explanation of the purpose of the form can be given as a ‘subtitle’ under the main title.’ form is not obvious. The title should tell readers why the form is important. and purpose of If the title of the new collecting the information. 3. Purpose Unless readers are made aware of the importance of the information being requested. The form might also have an abbreviated title by which it is commonly known—for example. • have a clearly recognisable title. careful consideration should be given to choosing a meaningful title that describes its function. and purpose of collecting the information. it will be given little attention and will not be completed properly. ‘Diabetic Treatment Form’. To assist readers to understand the purpose of a form. ‘DTS’. Title All forms should be identified by a title that clearly explains the purpose of the form—for example. the nature of the information required. and • seek information logically. • have a clear layout that leaves enough room for written entries to be made clearly and easily. they will not make a significant effort to provide it. A discussion of these six features forms the framework for this chapter. . • be presented in a fashion that is easy to read and easy to complete.

.’. By completing this form. The title (‘Social History and Lifestyle’) clearly identifies the form and the explanation is designed to help the person filling in the form feel comfortable about supplying the requested information. Presentation Typefaces Care should be taken in the choice of typeface because some typefaces can be difficult to read. A common example is Times New Roman. For example. Serif typefaces are easier to read— and are therefore best used in general text. Sans-serif typefaces have a clean ‘modern’ look—and are therefore commonly used for headings. • A sans-serif typeface is one without ‘hooks’ on the ends of the letters. 4.’ to be intrusive. This convention is followed in the typefaces used in this book. excoriation. Many of the questions asked ‘A brief paragraph of explanation can be useful in allaying concerns of people who are admitted to and encouraging respondents to residential-care facilities can appear supply information. A brief paragraph of explanation can be useful in allaying concerns and encouraging respondents to supply information. a form headed ‘Skin Integrity Audit’ might be subtitled: ‘To assist in patient wellbeing by identifying skin problems related to pressure. a nursing home might explain its ‘Social History and Lifestyle’ admission form in the following terms: To make your stay as pleasant as possible. you will help us to understand you better and cater for your needs to the best of our ability. The typeface that is chosen should be easy to read.4 (page 200) shows some serif and sans-serif typefaces.199 Effective Design for Documentation For example. rashes. Figure 14. we wish to learn about you and your life experiences. A common example is Arial. In general. and should be used consistently throughout the form. etc. • A serif typeface is one with little ‘hooks’ on the ends of the letters. there are two types of typeface.

4 Serif and sans-serif typefaces It is best to limit the number of different typefaces used in a document. Too many different typefaces can give a messy and confusing appearance. See Figure 14.5 (below). According to modern publishing convention.5 Different point sizes AUTHOR’S PRESENTATION To emphasise particular words or phrases. bold and underlining are used in headings. Graphical and pictorial representations Some information is best recorded in a graphical or pictorial format.200 Nursing Documentation Aa Bb Cc Serif typeface AUTHOR’S PRESENTATION Sans-serif typeface Aa Bb Cc Figure 14. and well-designed forms should make allowance for this in recording certain data. A good rule is to use a maximum of two different typefaces in one document. Variation can be introduced by using different point sizes to alter the height of the letters—as shown in Figure 14.6. Other vital signs and clinical information are also conveniently recorded . italics should be used. graphs of temperature are familiar to nurses as an appropriate way to record and communicate information. Times New Roman 14 Point Times New Roman 12 Point Times New Roman 10 Point Arial 14 point Arial 12 point Arial 10 point Figure 14. but are now less commonly used for emphasis. page 201. For example.

For more on the use of these scales. Because there is no objective way to measure pain. However. An example of the first is the recording of pain intensity in persons who have trouble communicating because they have a cognitive impairment (such as dementia). page 129.201 Effective Design for Documentation Italics are used to emphasise Bold and underlining are used in headings Figure 14. . In designing forms that record this sort of information. A ‘faces scale’ can be useful in recording this information.6 Use of italics. Sometimes the information being sought is subjective. care must be taken in interpreting these sorts of facial scales. For more on the use of these scales. page 125. see ‘Rating scales’. nurses ask residents to express how they feel. In these cases. These are useful in two ways: • to record subjective data from people who might have difficulty in communicating their feelings. a numeric scale can be helpful. and underlining AUTHOR’S PRESENTATION on graphs. Chapter 9. A typical example is an assessment of pain. Pictorial representations can also be included in forms. Such a scale is a pictorial representation of facial expressions that range from a broadly smiling face to a clearly distressed face. Chapter 9. see ‘Rating scales’. it is important to include well-designed blank graphs appropriate to the data to be recorded—with time on the horizontal axis and the vital sign to be measured on the vertical axis. Numeric scales are used to indicate the resident’s reported pain intensity on a scale from 1 to 5 (or 1 to 10)—with 1 being ‘no pain’ and 5 (or 10) being ‘the worst pain imaginable’. This information can then be recorded on a numeric scale included in the form. and • to save time and words in describing a particular part of the body. bold.

numeric scales. It is best to use an initial capital for the first word. Text and headings that are written entirely in capital letters can be difficult to read. Abbreviations Abbreviations are best avoided in nursing documentation because they can cause confusion. These should also be explained (at first use) on the form itself—no matter how self-evident the abbreviation might seem to be. Capitalisation There is a general policy in modern publishing to minimise the number of capital letters that are used. ‘Nurses should use only approved the reality is that nurses abbreviations. Capital letters should not be used unless there is a good reason (such as for the formal name of a person or organisation). or pictorial representations are included in forms. with the rest of the sentence or heading being in lower case. numeric scales. They also have a ‘heavy’. Recognising this. However.’ some aged-care facilities have a list of approved abbreviations. . and clear instructions on their use should be included. in some cases. Such confusion decreases clear communication and. and clear instructions on nurse can then record the resident’s their use should be included. matter how self-evident the abbreviation might seem to be. oldfashioned appearance. If graphs.’ response on the diagram and include this in the patient’s record. These should be do sometimes need to use explained on the form itself—no abbreviations. Such a diagram can be ‘Graphs. The use. they should be carefully designed for ease of use. In designing a form. nurses should use only approved abbreviations. A diagram of the human body can be used to gather the information and to record it. this can have legal consequences. or shown to a resident—who is asked pictorial representations should be carefully designed for ease of to indicate the location of pain.202 Nursing Documentation An example of the second use of a pictorial representation is in recording the location of pain.

Instructions Clear instructions As previously noted (page 199). Dates Different cultures use various formats when writing dates.’ completing this form’). a phrase or short sentence in capital letters is useful to emphasise a particular point.203 Effective Design for Documentation In some cases. and a note placed on page 1 to indicate that page 2 must also be completed. If the form continues to a second page. If a second page is printed on the back of the first page. in modern publishing. some organisations have a policy of never printing on both sides of the page. If a published form is dated. However. an identifying header should be included on the second page. a note at the bottom of the first page should be included—for example. This is to ensure that the entry is easy to read—because some handwriting can be difficult to decipher. any instructions for completing a form should be carefully stated at the beginning. If the form is to be filled out using capital letters. it is therefore best to express the date in full (using numbers and words)— for example. a subtitle or explanatory introductory paragraph is useful in assisting people to understand the purpose of a form. because people can overlook a page that is printed on the back of another page. . Some forms ask people to use BLOCK CAPITALS when they fill in the form. In a similar way. This variation can cause confusion. For example. the convention is that italics are used to indicate emphasis (rather than capital letters or underlining). 13 December 2005. a form might have ‘Any instructions for completing an instruction to use block capitals a form should be carefully (‘Please use BLOCK CAPITALS in stated at the beginning. However. For example. Americans put the number of the month first and the number of the day second. ‘Please turn over and complete page 2’. this instruction should be given at the beginning of the form.

For example. Too much space can result in unnecessary detail being provided. If additional information is required in addition to a ‘yes’ answer. this should be clearly indicated. please give details: Note that the request for details should immediately follow the ‘yes’ response option with sufficient space for the response. guidance should be provided as to how the date is to be recorded. Allowing too little space can result in important information being omitted. Clear instructions should be given on the form—such as ‘circle one’ or ‘tick one’. Questions with alternative answers Some questions request that an answer be chosen from multiple alternatives—of which one or more must be selected. For example: War service? (circle one) No Yes If yes. Careful consideration should be given to the alternatives that are provided.204 Nursing Documentation If the person who fills in the form is required to enter a date. Unless care is taken.’ In most cases this will be by circling the chosen alternative or marking a box. This should be specified on the form with clear instructions. confusing or ambiguous alternatives might . to the alternatives that are provided. The reader should be instructed as to how the ‘Careful consideration should be given selection is to be indicated. a form might request that a birthday be filled in as follows: Date of Birth: ___ (day) – ___ (month) – ___ (year) Yes/no answers Many form questions have a ‘yes/no’ option as a possible answer.

Only essential or required information should be requested of the reader.205 Effective Design for Documentation be offered. . the requested information should be information that is really required. it is important to ensure that every question earns its place. There are two obvious ways to avoid cramped forms—use more than one page and/or decrease the number of questions. The alternatives should read: Age group? (circle one) Under 5 5 to 10 11 to 20 etc. followed by a suitable space. In considering the number of questions. A good test is to look at the form and ask: ‘Is this form user friendly? Would I like to complete this form myself?’. A crowded form discourages the reader—leading to mistakes and omissions. Consider the following example: Age group? (circle one) Under 5 5 to 10 10 to 20 etc. Layout The form should not be crowded and difficult to fill in. In this example. If a question is asked. in requesting a respondent to choose an age group. the age of 10 years is included in two alternatives. include an ‘other’ category. 5. care should be taken to ensure that there is no overlap. This should be accompanied with the instruction ‘please specify’. Sufficient space should be left between lines for handwriting. For example. If the multiple alternatives do not encompass every possibility.

206 Nursing Documentation 6. Other information Every form is different. Some of these matters (such as dates of birth and age) have been discussed above. Signature If the form requires a signature. Whatever information ‘ … a logical order that makes sense— both for the person who is filling in the is required on particular form and for the person who is compiling forms. It should be remembered that non-Christian people do not have a ‘Christian’ name and that some Asian people place the family name before the given name. If the person speaks more than one language. the form can ask the person to indicate the language in which he or she is most fluent. Forms usually start with names. Language spoken The form should ask the reader to indicate what language (or languages) he or she speaks. it might be necessary to allow room for a witness to the first signature. Space should also be allowed for dating any signatures. Seeking information logically Names Information should be obtained in a logical order.’ to ensure that the information is collected in a logical order that makes sense—both for the person who is filling in the form and for the person who is compiling data and records from the form. Space should be allowed for the name of the witness to be entered in block letters beside the signature of the witness. care should be taken data and records from the form. Other cultures do not have a family name and a given name. and it is not possible to discuss every possible piece of information that might be required in the many different forms used in residential aged care. In some cases. Information should be requested in a way that is acceptable in a multicultural society. It is best to ask for a ‘first name’ and a ‘second name’ (and perhaps a preferred name). sufficient space should be provided for the person to sign his or name. .

should It is illegal to reproduce and be included on the form. Conclusion Well-designed forms have a number of important benefits. A date should be added to the form to show when it was designed.’ to seek permission to use the form if they wish to do so. A few copies should be made and given to nursing colleagues for a trial. Forms designed by other people should not be used without permission. A review date should also be added—to indicate when the form should be checked to ensure that it is accurate and appropriate for its purpose. Trials It is difficult to design a form perfectly the first time. Identification The designer’s name. Review date Nursing knowledge and procedures are not static. It is illegal to reproduce and use a form without the written permission of the copyright owner. In many instances this is a legal requirement. Appropriate amendments should be made to the form. This process might need to be repeated several times.207 Effective Design for Documentation Many forms require the signature of a nurse. Obtaining a useful form that serves its purpose is worth the time and trouble of getting it right. . Feedback and suggestions should be welcomed and considered carefully. name of the organisation. They are easier for staff to use—and therefore save time and decrease frustration. forms are covered by copyright. and the ‘Forms are covered by copyright. There should also be room for nurses to print their name and designation. As with other created ‘works’. This use a form without the written information enables other people permission of the copyright owner.

’ professional care.208 Nursing Documentation The information that they contain is easy to read and understand— thus improving communication. data collection. well-designed forms ‘Well-designed forms enhance general enhance general standards of standards of professional care. and record-keeping. . Finally.

A system is a complex set of connected parts that enables a process to be approached in an ordered and methodical manner. various aspects of nursing documentation. However. This final chapter takes a broader view of the subject in presenting a systems model for professional nursing documentation in aged care. the chapter earlier chapters—and presents draws together many of the topics them in one coherent model. in detail. the model presented here puts many of the topics of earlier chapters into an overall context. In ‘This chapter draws together presenting a systematic overview many of the topics considered in of documentation. In doing so. This final chapter does not attempt to go over everything that has been covered in detail in earlier chapters. 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.Chapter 15 A Systems Model for Documentation Christine Crofton and Gaye Witney Introduction Earlier chapters in this book have discussed. To ensure that .’ considered in earlier chapters—and presents them in one coherent model.

Nurses working within such a system find it easier to strike the right balance between the demands of documentation and the provision of nursing care. Staff involvement in the process can help to ensure ‘ownership’ of the model. In short. such a review can be of benefit to nurses—by identifying the issues that documentation creates for nursing staff. However. Although a systematic approach is complex to establish. and this can cause some discontent in the short term. Such professional documentation and a system also assists and guides positive resident outcomes. and the development of clear guidelines and processes that are of benefit to nursing staff and the organisation as a whole.’ staff in ensuring that residents are managed appropriately and that all relevant aspects of nursing care are recorded. a systems approach ensures that all areas of the organisation are committed to quality documentation with a clear delineation of responsibilities. The existence of such a system gives a clear message to all staff members—that the ‘The existence of a system gives a organisation is serious about clear message to all staff members— professional documentation and that the organisation is serious about positive resident outcomes. holistic nursing care is enhanced. If nurses feel supported in a coherent system of professional documentation. Such a systematic . it is essential to have a well-organised documentation system in place. it actually simplifies documentation for nurses and clearly delineates their responsibilities in the process. In particular.210 Nursing Documentation documentation becomes an integral part of professional nursing practice in an aged-care facility. It takes courage and energy to review the current status of documentation within an organisation and to identify necessary changes. such a ‘Staff involvement in the review is likely to identify timeprocess can help to ensure management issues and the pressure “ownership” of the model.’ that these place on individual nurses. A documentation system integrates an organisational approach to documentation—rather than relegating documentation to the status of ad hoc notes that individual nurses write at the end of each shift. Habitual staff practice will be challenged.

Preparatory work Before establishing a system of documentation in a facility. and that continuous quality improvement is maintained. and • the role of research. • the importance of evidence-based practice in any documentation system. This preparatory work involves management and nursing staff addressing the following issues: • the place of documentation in the overall clinical governance of the organisation. when used in relation to documentation. can be defined as the developed understanding of what an organisation expects with respect to documentation. It is based on the principles of best practice and integrates many of the philosophical concepts that underpin contemporary nursing practice.1 (page 212). The term ‘culture’. • the overall philosophy of the organisation with respect to documentation.211 A Systems Model for Documentation model also ensures that all funding requirements are addressed. The model is shown in Figure 15. • the importance of a quality system. and the way . and is described in detail in the rest of this chapter. • policies and procedures. The model moves the responsibility for documentation from the individual nurse to the organisation as a whole—with accountability equitably shared across the many facets of an aged-care facility. Clinical governance and documentation The culture of an organisation is important in facilitating the successful implementation of clinical governance. Each of these is discussed below. The documentation model described in this chapter has been developed after many years of research and consultation with professional nursing colleagues. • issues of regulatory compliance. it is necessary to do some vital preparatory work.

1 Crofton–Witney documentation system AUTHORS’ CREATION .212 Nursing Documentation Clinical governance Evidencebased practice Preparatory Work Regulatory compliance Quality systems Research Policies & procedures Philosophy Education Assessment Tools Documentation Essentials Nursing-care plans Progress notes Auditing Assessment Benchmarking Publishing Figure 15.

• policies and procedures.213 A Systems Model for Documentation in which nurses respond ‘Clinical governance safeguards exemplary to that expectation in their standards and creates an environment in documentation practice. • the importance of a quality system. Clinical governance calls nurses to account. it is necessary to do some vital preparatory work. • ensuring the best-possible record of nursing care in every interaction with a resident.’ ‘Culture’ in this sense is what nurses refer to as ‘the way things are done’ within an organisation— the accepted practice and traditions of the organisation. and • the role of research. It ensures that ongoing improvement of documentation occurs—thus safeguarding exemplary standards and creating an environment in which excellence can flourish. Each of these is discussed in this section of the text. A professional nurse has a responsibility to ensure that documentation practices are contemporary. which excellence can flourish. Preparatory work Before establishing a system of documentation in a facility. Clinical governance is a framework for best practice. • the overall philosophy of the organisation with respect to documentation. • issues of regulatory compliance. This preparatory work involves management and nursing staff addressing the following issues: • the place of documentation in the overall clinical governance of the organisation. In terms of ‘culture’ and clinical governance. . • the importance of evidence-based practice in any documentation system. there are four stages in the successful implementation of a comprehensive documentation model: • establishing a partnership with residents.

1. and • developing documentation practices that increase career options. All the available evidence should be reviewed to ensure that documentation reflects current nursing practice. .214 Nursing Documentation • learning from experiences by reflecting on documentation practices. This step is thus about developing a culture of clinical governance in which the information to be documented is gathered through collaborative partnerships. talking to family and significant others when gathering information. Ensuring the best-possible record of nursing care in every interaction with a resident The second step is concerned with effectiveness when documenting nursing care and nursing management. Establishing a partnership with residents This first step involves listening to a resident when undertaking an assessment. and nursing care should be evaluated against resident outcomes. Timemanagement issues associated with documentation responsibilities should also be assessed. and informing a resident about options of nursing care. Each of these is discussed below. establishing best practice in documentation. These results should be documented. and relating this to nursing care and resident management. Benchmarking (see page 240) can help to establish how well the organisation is managing in relation to other organisations. and the results should be shared and compared with other nursing staff to improve the documentation process.’ residents when developing care plans. 2. This involves the identification of the important issues relating to assessment. The nurse must then collate the ‘ … developing a culture of clinical information for a residentgovernance in which the information focused nursing-care plan— to be documented is gathered through working collaboratively with collaborative partnerships.

This involves (CGST 2004): • participating in professional-development groups. Developing documentation practices that increase career options This stage involves nurses’ ensuring that they develop—both professionally and personally—rather that remaining stagnant with respect to their understanding of documentation practices. 4. and reflecting upon. Evidence-based clinical nursing practice involves decision-making on the basis of the best evidence available. and • challenging poor practice in documentation to enable colleagues to be proactive (rather than reactive) in dealing with documentation issues. • managing risks by identifying and avoiding mistakes when documenting. and • encouraging and participating in lifelong learning to ensure that nurses ‘catch the learning bug’ to enhance their documentation and professionalism. • sharing any research and evidence with colleagues within the organisation (and beyond). • identifying educational needs (both for the individual and the nursing team) to improve documentation.215 A Systems Model for Documentation 3. best contemporary practice in nursing documentation.1 (page 212). Learning from experiences by reflecting on documentation practices This stage in the process is about identifying. It also involves nurses’ being change agents by: • sharing any new information about documentation with colleagues. • mentoring other nurses to learn this process. . It involves nurses’ sharing knowledge about the documentation process. Evidence-based practice As can be seen in Figure 15. the preparatory phase of the Crofton–Witney model for documentation moves from clinical governance to evidence-based practice. In making clinical decisions. and being responsible for their own learning about documentation requirements.

. 30) observed: ‘Clinical excellence will flourish in an organisation that proactively responds to incidents. p. This enables Organisational responsibility for clinical governance This section of the text has discussed four steps in developing a culture of effective clinical governance with respect to documentation: • establishing a partnership with residents. As McSherry and Pearce (2002. • a proactive approach to addressing gaps in the documentation system. • implementation of documentation risk-management systems. • positive responses to complaints about the documentation system. • provision of professional development that is aligned to individual nurses’ learning needs. complaints and suggestions’. Organisations have a responsibility to support nurses in establishing these four steps. • holding poor performers accountable for their documentation. • learning from experiences by reflecting on documentation practices. and • access to high-quality research resources to support the documentation process. and • developing documentation practices that increase career options. • ensuring the best-possible record of nursing care in every interaction with a resident. • processes that encourage evidence-based practice in documentation. • leadership in implementing documentation systems and providing ongoing support and resources for that process. the key attributes of an organisation that actively supports clinical governance are: • integrated approaches to documentation processes.216 Nursing Documentation nurses must build on their personal professional knowledge and experience by systematically appraising contemporary research findings. According to these authors. • innovation in facilitating a sense of documentation being valued and shared.

• evidence-based abstraction services. there have been numerous advances in evidence processing in recent decades. Fortunately. • integration of the evidence into current practice—thus facilitating decision-making to improve documentation. credible. In undertaking a search for suitable evidence. • formally evaluating the evidence gathered (a process known as ‘critical appraisal’). . a nurse needs to assess the time that he or she has available. the availability of databases. Evidence-based practice relating to documentation is a five-step process: • defining the documentation issue that needs to be addressed.217 A Systems Model for Documentation objective clinical decisions to be made—rather than decisions being reactive. and • frequently updated textbooks (in hardcopy and electronic formats). • valid. or habitual. These include: • the production of streamlined guides to aid in critical appraisal of the literature. such evidence-based appraisal can be a difficult and time-consuming task. If performed conscientiously. • collecting evidence to address the issue. emotional. • clinically important. • electronic literature searching (both online and in other forms). and current. • high-quality systematic reviews (such as the Cochrane Collaboration). Effective evidence-based practice requires nurses to have evidence that is: • accessible and timely. and • applicable to the documentation system. and • evaluation of the five-step process with a view to improving it next time.

and to interpret and evaluate arguments with the intention of reaching a conclusion from a new perspective. These steps help to clarify issues and avoid questions that are vague and generalised (and therefore difficult to answer). (iii) implementation. how to do systematic reviews and searches. (iii) progress notes. With some services.218 Nursing Documentation The importance of critical thinking Nurses must be able to think critically if they are to decide what and how to document. and how well the issue lends itself to research. They also provide guidance as to where pertinent evidence might be found. (ii) care plans. guidelines. Speedy & Jackson 2000. An inability to ask focused and precise questions can be a major impediment to evidence-based practice. Sources of information and evidence might include colleagues. a database on methodology for conducting systematic reviews. An excellent example of a structured review database is the Cochrane Collaboration (Cochrane 2004). textbooks. Evidence-based abstract services from journals are also useful. It challenges nurses to investigate assumptions about current information. The studies are analysed using standardised methodology and meta-analysis. Such critical thinking involves ‘ … questioning what is usually taken for granted’ (Daley. and systematic reviews. and • classifying the question into the components of documentation—(i) assessment tools. The articles are summarised in ‘value-added’ structured abstracts and have a commentary by content experts. policies and procedures manuals. journal articles. This skill can be improved by: • breaking the question down into the stages of documentation—(i) assessment. and how to obtain information about existing groups). complete collections . p. (ii) analysis. and (iv) associated supporting materials. The database also includes abstracts of non-Cochrane systematic reviews. and the Cochrane handbook (which contains information on how to form review groups. 249). and (iv) evaluation. government and professional guidelines. of evidence desired.

and year of publication. Philosophy As can be seen in Figure 15.’ information is available at its website. graphs. produced by the National Library of Medicine in Bethesda.1 (page 212). A philosophy is the set of beliefs of an organisation. • the ethical considerations linked with documentation. the preparatory phase of the model for documentation being discussed in this chapter now moves from evidence-based practice to philosophy. and • an organisational model for documentation. is the best-known bibliographic database of biomedical journal literature. • the impact of multidisciplinary teams on documentation outcomes. topic. . A wide range of the best ways to find newly of current comprehensive healthcare published information.219 A Systems Model for Documentation of structured abstracts and commentaries can be searched by keyword. study type. Many journals are now available full-text via the website (Medline 2004). a search of current hardcopy journals in the field is still one of the best ways to find newly published information. tables. USA. an organisation needs to consider: • basic beliefs and values relating to documentation and documentation practices. Apart from such online databases. • management practices that affect documentation. • the availability of environmental and human resources to support the documentation process. Medline. complete with charts. Maryland. and illustrations. In developing such a philosophy. Another online service is that ‘A search of current hardcopy presented by Cinahl Information journals in the field is still one Systems (Cinahl 2004). It is important that an organisation indicates its views on documentation and develops a specific philosophy on the subject.

The Box ‘A vision is the ‘dream’ for the on page 221 lists some important organisation … a mission is the implementation of that points to be considered by any dream in practical terms. A consideration of the issues canvassed in the Box will assist in the development (or review) of a documentation philosophy. It is essential for the organisation to have such a documentation philosophy—to ensure . The developed philosophy of the organisation flows from this picture. An effective leader must: • identify how documentation fits into the organisation’s goals. In developing the philosophy.220 Nursing Documentation Leadership is required to develop a documentation philosophy. Staff members will then understand and value their roles within the participatory process.’ organisation when developing a philosophy of documentation. and how to accomplish them. Before a philosophy is developed it is important to identify the organisation’s vision and mission. Authority and accountability are required at all levels of the organisation. Authority dream in practical terms. • inform nursing staff and provide appropriate supporting resources. The philosophy should be published and readily available. A vision is the ‘dream’ for the organisation. participation by staff is essential. the vision and mission levels of the organisation. • clarify documentation requirements and any associated standards. • provide education when gaps are identified in documentation processes and practices. whereas a mission ‘Leadership is required to develop a is the implementation of that documentation philosophy. Taken and accountability are required at all together. and • review processes to ensure progress towards positive resident outcomes through documentation. and will appreciate that the organisation values them.’ of an organisation create a picture of what is expected from all involved within the organisation.

• Does the organisation promote the importance of documentation? • Is the organisation a facilitator of change in documentation processes? • How creative is the organisation when documenting nursing-care issues? Specific questions In more specific terms.221 A Systems Model for Documentation Questions to be addressed General questions In drawing up a philosophy for documentation. page 212) now moves from the development of an organisational philosophy to the question of regulatory compliance. Does the organisation: • have a documentation committee? • have documentation systems in place to support staff? • encourage excellence in documentation? • have confidence in its own approach to documentation? • involve the team in decisions about the documentation? • have written guidelines about the documentation required? • work to create a learning culture in which staff members can confidently learn new documentation skills? • present a positive image when speaking about and dealing with documentation issues? • tolerate and promote individuality within its documentation systems and within its staff practices? that a clear indication of the organisation’s expectations is given to all members of the multidisciplinary team. the following questions should be addressed. an organisation should address the following general questions.1. and to ensure that all members are aware of their individual responsibilities in the process. . Regulatory compliance The preparatory phase of the Crofton–Witney model for documentation (see Figure 15.

certain specific legalities and regulations are ‘As professionals. objectively. In an era in which litigation is common. and nursing documentation records that duty of care. nurses are obliged to document clearly. and legibly. Erasers or ‘whiteout’ should never be used. . required to uphold a duty of Because nursing documentation care. and should be signed with a clear indication of the name and designation of the person making the entry. All entries should have a notation of the date and time. entries should not be postponed until the ‘Nursing documentation is end of the shift. a signature. nurses must be aware of their legal responsibilities under the statutory Acts and common law rulings that govern their practice. and there should be no additions or alterations entered at a later date. and nursing documentation records nursing care.222 Nursing Documentation As professionals. All nurses must be aware of relevant legislation and regulations governing nursing practice within their own legal jurisdiction. Nursing documentation is legal documentation. documentation records that duty of care. and a date. Even if there are no specific legal requirements with respect to documentation in particular jurisdictions. All entries should be in legal documentation. If an organisation does not physically possess these documents. nurses are required to uphold a duty of care. accurately. nurses are associated with the nursing role.’ can bring the nurse into situations in which legal and regulatory issues need to be considered. There should be minimal use of abbreviations and jargon—to ensure that there is no confusion as to exactly what the entry means. the organisation should ensure that they are available to nurses through the Internet. Entries should be recorded as events happen. If an error is made. and society’s legal and regulatory requirements reflect many of these expectations. and must have access to these within the workplace. concisely. Apart from a general requirement to practise nursing in a professional manner. there should be a clear indication of the change that has been made—with a line through the incorrect entry.’ chronological order. Society has expectations of the nursing role and the standards of documentation associated with it.

Nurses also important enough to be talk about care and associated issues recorded in writing. It is important that nurses recognise that something important enough to warrant discussion is also important enough to be recorded in writing. nurses must also respect issues of confidentiality. They must be guided by legislation and the organisation’s policies with respect to other people requesting information. traditional nursing to warrant discussion is culture is an oral culture. . this can imply that something that has not been written down has not been done. and • any specific legislation relating to health records and the role of the nurse. p. • requirements under workplace safety legislation regarding incident reporting. • privacy legislation and its effect on nursing practice in relation to the collection. Nurses thus have an obligation to protect resident records. security. Nurses must safeguard themselves against this implication. and disclosure of information. ‘Something important enough In many ways. use. In these matters it is important that nurses reflect on: • the scope of practice in the relevant Nursing Act in their jurisdiction.223 A Systems Model for Documentation If documentation is not maintained. 76) observed: [A] breach of professional code of ethics and legislation controlling registration by a health professional may result … in the initiation of disciplinary proceedings by the professional regulating body [and] also raises concerns as to the legal implications of third parties having unauthorized access to information. • what the law requires in relation to documentation in general and aged-care standards in particular.’ in discussion among themselves during handover or team meetings. Although proper documentation is essential to effective resident care. As Forrester and Griffiths (2001.

vision. To ensure that a quality system is developed. the model shown in Figure responsibility. courage. . and commitment. ‘do’. it can be useful to have someone on the committee designated as being responsible for continuous monitoring of ‘Comprehensive audits of procedures such regulatory issues to dealing with the collection. positivity. and ‘act’ (PDCA) (HCi 2004).1 (page 212). The PDCA model has seven steps. an organisation requires leadership. The CQI cycle can be used for improving any stage of the documentation process. vision. The model described here incorporates the Deming principles of ‘plan’.’ current requirements. responsibility. When the CQI process is implemented it identifies nonproductive phases of the system. courage. Quality systems A documentation system must include processes for continually working to improve the standard of nursing care and documentation. which can then be reviewed—making the overall documentation processes more effective.’ 15. storage. • mapping the documentation system. and maintenance of resident information is essential and must be included in the documentation systems of all organisations. These processes constitute a ‘quality ‘A quality system … requires system’—the next step in leadership. Contemporary management practice requires organisations to have systems in place to ensure that continuous quality improvement (CQI) occurs. and ensure that the organisation maintenance of resident information and nursing staff are must be included in the documentation informed of changes and systems of all organisations. and commitment. positivity.224 Nursing Documentation Comprehensive audits of current procedures dealing with the collection. storage. Finally. To improve a documentation system it must first be described and modelled. These are: • defining the scope of the documentation system. ‘check’. if there is a documentation committee.

In this step. improvements are identified. The key objective is to establish who does what and when—and then to measure performance in the discharge of those responsibilities. 3. Each of these is described below. improving the CQI process. the stakeholders in the process are identified. Analysing the CQI process In this step. There are two types of performance targets: • performance standards—the raising of standards to a consistent level of excellence across all levels of nursing staff. 1. 2. setting CQI process targets. and review. 5. 4. Mapping the documentation system A mind map or flowchart provides a shared understanding of how the documentation process operates. Defining the documentation system measures Qualitative and quantitative measurements are applied to enable data to be collected about the status of the system. the main purpose and scope of the documentation process are defined. and • performance objectives—what is to be achieved once the outcomes of the measures have been analysed. Defining the scope of the documentation system This is important for providing a solid foundation for making improvements in the system. Setting CQI process targets CQI targets are needed to guide the process of improvement in the desired direction. The process is analysed from three perspectives: . analysing the CQI process. and clarifying the process—thus allowing opportunities for improvement to be identified. analysing.225 A Systems Model for Documentation • • • • • defining the documentation system measures. It also provides a means for discussing. In addition.

. The next CQI cycle is then initiated.226 Nursing Documentation • the people perspective—the resources. A documentation policy thus ‘A policy is made up of statements of states the principles that principles that allow staff members have been adopted by an to use their discretion while working within accepted boundaries. Policies and procedures The Crofton–Witney model for documentation being discussed in this chapter (see ‘Preparatory work’. It is made up of statements of principles that allow staff members to use their discretion while working within accepted boundaries. competencies. Improving the CQI process This step incorporates the Plan/Do/Check/Act (PDCA) cycle. and • process perspective—the bottlenecks. non-productive steps. Such a policy is derived from the philosophy of an organisation (see page 219). with a special focus on managing change (especially the human aspects) in the process.1. Policies A policy is a guide to practice.’ organisation with a view to achieving optimum documentation outcomes. the results of the entire CQI cycle are reviewed and its outcomes are communicated to all stakeholders. Review In this step. • the technology perspective—the adequacy of technical support. Documentation policies define strategic direction and reflect a systematic approach to the management of contemporary documentation. and suitability of the organisation to manage a documentation system. Figure 15. 7. and validated problem areas in the documentation system. The PDCA cycle is also extended by a further step of review— whereby the immediate results of an improvement action are reviewed. page 212) now moves to the question of policies and procedures. 6.

Management should always seek collaboration from the nurses to promote ‘ownership’ of the developing policy. They provide for ‘Documentation policies … uniformity of actions for all nursing indicate that management staff members associated with has a commitment to quality documentation. and encourage ethical documentation practice. it is important that management listens to the nursing staff. Such policies provide a guide to nurses with respect to documentation practices. • detail prescribed actions to be taken when documenting.227 A Systems Model for Documentation Characteristics of policies Documentation policies are guidelines that: • reflect the documentation philosophy of the organisation. It is useful to hold brainstorming sessions to collect ideas about the content of the proposed documentation policy. and indicate that management has a commitment to quality documentation. Policies must be written down.’ resident management. If nurses are not included in the process in a meaningful way. This establishes standards of performance expected with respect to documentation. • reflect regulatory compliance. promote consistency in documentation. Before doing so. Such policies also provide a communication tool that promotes collaboration and cooperation within the team with respect to documentation requirements. If documentation is inadequate. having definite policies allows for the counselling of staff members on the basis of established principles. • clearly spell out documentation responsibilities of the nursing staff. they can feel that the whole exercise . • state precisely the constraints that are placed on documentation processes. • provide direction for decision-making in documentation. and • ensure that documentation is undertaken within the scope of the current practice and designated roles of the nursing staff.

• enable a clear approach to be followed. . Research The final step in the preparatory phase of the model being discussed (see Figure 15. Information regarding the required documentation processes can be passed onto staff in many ways—including handovers. and required standards are unlikely to be achieved if nurses have little or no understanding of the policies. rather than regular staff being obliged to undertake it all. • promote best practice. • support nurses who are unfamiliar with the facility—thus enabling them to be involved with documentation. page 212) is research. A procedure thus outlines the individual actions that are to be followed to meet such requirements. Procedures are important because they: • communicate to staff the expectations relating to documentation.228 Nursing Documentation is a cynical process of tokenism—thus devaluing the whole process. Rather than being agreed and valued. the whole system can be perceived as being imposed and irrelevant. It can also specify the standard at which the documentation is to be undertaken. nursing staff meetings. A ‘procedure’ is a sequential step-by-step approach that is to be followed to meet the requirements of policy. It is essential that an organisation has a clearly established documentation process. Procedures Documentation policies are implemented through procedures. and that guidelines describing the process are available and accessible.1. and • reassure residents and families that quality documentation is occurring. They should be adjusted as changes in documentation requirements occur within the organisation or industry. and appraisals. Policies should not be set in concrete.

or a particular database? Some background reading should be done to gain various perspectives of the aspect of documentation being researched. Defining the topic The process begins by clearly mapping-out the concepts to be researched. or both? • If the research has been requested by the organisation. • locating the information identified in these resources. The researcher’s understanding of the topic can be clarified by asking the following questions: • What level of research does the documentation project require? For example. The research process is basically a process of five steps: • defining topics about various aspects of documentation. 1. Some key resources that will help in gathering this information are: • dictionaries and thesauruses—dictionaries provide an alphabetical listing of words and phrases followed by their definitions. This identifies the key terms and key concepts to be used when searching electronic databases and print research resources. many nurses are uneasy about library research. • evaluating the resources.229 A Systems Model for Documentation When trying to establish details of current practice in documentation. Many do not know how or where to start. has the organisation requested that the research include certain types of materials—such as journals. and • documenting and disseminating the findings of the research. . This will also generate relevant keywords to use during database searching. does the project involve a brief staff presentation or does it involve the writing of a research paper on documentation with a bibliography and footnotes? • What is already known about this aspect of documentation? • What are the main issues? • Does the topic deal with historical or current events. Each of these is discussed below. • selecting and using the best research resources. whereas thesauruses contain subject headings that list synonyms and related words. newspapers.

• material recommended by experts in documentation. Using key words or key concepts identified in the mind map discussed above.230 Nursing Documentation • handbooks and research guides—a handbook is a resource or guidebook to a subject. Some libraries produce bibliographies of their major print research ‘Librarians can be very helpful to nurses in seeking out information. and electronic databases are the major research tools used to locate articles and conference papers that deal with advanced research. • bibliographies—bibliographies contain a systematic list and/or description of the literature on a specific subject (including authorship and publication details). abstracting journals. • bibliographies of books and articles on documentation. and • online help (using search engines). Selecting and using the best research resources Resources for basic research Information for projects that do not require in-depth study can usually be found in journal articles or current texts. research guides provide an overview of the research process in a given area. These sorts of resources can often be found in libraries. the library catalogue can be used to find: • books and journal titles held at the library. • government resources and manuals that have been produced to guide the documentation process. Handbooks and dictionaries are often shelved in a library’s reference collection. These resources provide basic descriptions . The information collected can be used to create a mind map—a useful method of devising a strategy for finding information in print and electronic research resources. Resources for advanced research Indexing publications.’ resources. Librarians can be very helpful to nurses in seeking out this information. 2.

sorting. Guides to searching electronic databases and subjectspecific guides are helpful in researching Internet and print resources. Search engines and subject directories are helpful. but they are mixed in with items of little or no value—and finding something useful can involve spending a great deal of time in sifting. Some databases now provide the full text of the article. the broad subject area that covers the topic should be selected from the subject page. Many indexes are now available as electronic databases. Indexing publications (usually referred to as ‘indexes’) list basic descriptions of articles and other literature relevant to documentation. All subject pages list relevant databases. under subject groupings. nurses can try an expert keyword search—combining the subject area with the term ‘abstracts’ or the term ‘indexes’ (for example: ‘abstracts’ AND ‘documentation’). ‘The Internet is an increasingly useful source of information. The librarian should be asked about the availability of such resources. Abstracting journals (usually referred to as ‘abstracts’) provide similar information to indexes. To find relevant indexes and abstracts. These are usually grouped by subject and/or author. To locate relevant electronic databases. although quality can vary. Some libraries produce bibliographies of their major print research resources. Many print indexes and abstracts are now available in electronic format—which facilitates quick and easy scanning for information. The librarian should be asked about these resources.231 A Systems Model for Documentation of articles and enough information for a nurse to see if the material is appropriate. The Internet provides access to a wide range of information stored in networked computers around the world. The abstracts are usually listed numerically. followed by the category .’ abstracts and indexes—which are often shelved in a separate collection within a library. and selecting. The broad subject area that covers the topic should be selected. The library should be checked for although quality can vary. Some items are of true value. The Internet is an increasingly useful source of information. as well as providing a summary of the article.

Most ‘Printed material is not always reliable— research publications have even if it appears in apparently reputable an editing or peer-review journals.232 Nursing Documentation ‘Internet resources’. Evaluating the resources Print resources Printed material is not always reliable—even if it appears in apparently reputable journals. their location. Some libraries have subject librarians. a direct search of Internet can be undertaken to see if the subject has a bibliography of selected Internet resources. If the catalogue shows the item is already out on loan. An electronic application form is usually available. Locating the information identified in these resources The library catalogue should be checked to see if the library has the items that have been identified during the searches. and discussions with these people about the focus of the research can help to clarify what is required.’ relevant information. Such ‘A research consultation with a a research consultation can librarian can often be the most often be the most effective and effective and efficient method of efficient method of seeking seeking relevant information.’ the authority and accuracy . If the items are found in the catalogue. Again. the library staff should be consulted. If an item cannot be found but the catalogue indicates that is should be available. and status should be noted. 3. Before beginning any search. Material from other libraries and tertiary education campuses can be sought using the inter-campus library delivery service to bring the required item to the local library. arrangements can be made for library staff to make contact when the item is returned. call number. Critical thinking is required in process that helps to verify assessing the information found on a topic. the librarian will often provide useful guidance. Critical thinking is required in assessing the information found on a topic. 4. a research consultation with the librarian can be very useful. Alternatively.

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of the information presented. Reputable newspapers and magazines also check their facts. However, it is still important to consider such issues as objectivity, currency of the information, and how thoroughly the topic is covered.
Internet resources

Many Internet resources lack the peer-review processes of print journals, and many fail to check basic facts before posting them on the Internet. This means that the user must thoroughly evaluate anything encountered on the Internet before deciding whether it is to be used in the research stage of a documentation project.
5. Documenting and disseminating the findings of the research

It is important to cite and document all the resources that are used in the research—especially if the work, ideas, or phrasing of other people are quoted or paraphrased. This includes anything found ‘It is important to cite and on the Internet. If sources are document all the resources that are used in the research—especially if not properly cited, this can be the work, ideas, or phrasing of other considered plagiarism—a serious people are quoted or paraphrased.’ form of academic dishonesty that can be construed as theft. When photocopying articles that might be used, the bibliographic details should be carefully recorded. This will save a lot of time that would otherwise be spent in trying to track them down later. Depending on the format of the project, it will be necessary to compile a reference list, footnotes, or a bibliography—or a combination of these.

Summary of preparatory work
The initial steps in establishing an effective systems model for documentation (see Figure 15.1, page 212) are therefore: • clinical governance; • evidence-based practice; • philosophy;

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regulatory compliance; quality system; policies and procedures; and research. If these first steps in the systems process are not in place, an organisation will find it difficult to meet documentation requirements. In dealing with documentation ‘In dealing with documentation issues, organisations must issues, organisations must become become proactive, rather proactive, rather than reactive.’ than reactive.

• • • •

Having completed the preparatory work, the next stage in developing a comprehensive model of documentation (see Figure 15.1, page 212) is the development of an educational program. An educational program is an essential step in establishing positive attitudes to documentation. In particular, such a program can develop the capacity of nursing staff members to think critically about their documentation practices. Critical thinking involves: • reasoning; • reaching a conclusion; and • forming a mental picture that is different from original perceptions. The critical thinking process is reflective. It involves reasoned thinking about issues with a focus on deciding what to believe and what to do—without necessarily ‘An educational program is an seeking a specific solution. essential step in establishing positive When applied to documentation, attitudes to documentation.’ critical thinking challenges nurses to look at assumptions about current documentation practice, and to evaluate arguments with the intention of forming a new perspective.

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Some definitions
Critical thinking Critical thinking is the rational examination of ideas, inferences, assumptions, principles, arguments, conclusions, issues, statements, beliefs, and actions (Bandman & Bandman 1998). Cognitive function Cognitive is an intellectual process by which one becomes aware of, perceives, or comprehends ideas. It involves all aspects of perception, thinking, reasoning and remembering (Como 2002, p. 389).

When developing an educational program that supports critical thinking about the documentation system, the following principles should be kept in mind: • staff members should be involved in collaborative decisions; • a draft program should be prepared for review; • pilots and trials should be conducted; • documentation research projects should be established; • ongoing evidence-based documentation practice should be promoted; and • documentation projects should be benchmarked. Best practice in implementing an educational program includes an analysis of nurses’ learning needs to identify any gaps in their knowledge, skills, and attitudes with respect to the documentation system. Once these are identified, a program that encourages critical thinking can be developed. Education in documentation should be part of an organisational culture of lifelong education. Such lifelong learning involves educational and life experiences that increase knowledge and skills throughout life. It is a learner-centred process that enhances quality of life and involvement in society through personal growth. Effective educational experiences for nurses involved in documentation enable them to grow personally, as well as professionally.

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Principles of adult learning
When planning an educational program, the principles of adult learning should be utilised. These include: • recognising life experiences and prior knowledge related to documentation; • acknowledging the values, beliefs, and opinions that nurses bring to their documentation practice; • allowing choices and self-direction in the educational exercise; • engaging nurses in their learning about documentation; • linking new knowledge to previously acquired information and experiences about documentation; • treating each nurse as an individual and allowing each nurse to express himself or herself through the educational experience; • offering educational exercises that involve practical application and problem-solving; and • enhancing lifelong learning with ongoing educational challenges related to documentation.

Documentation essentials
The next stage in the Crofton–Witney model of documentation (Figure 15.1, page 212) is the use of the essential documents of nursing practice. This stage involves a consideration of: • assessment and nursing diagnosis using nursing-assessment tools; • nursing-care plans; and • progress notes.

Assessment and nursing diagnosis using nursing-assessment tools
Advantages of assessment tools

Assessment tools are used to identify risk factors that might affect a resident’s capabilities. Such tools enable the nursing process to be implemented in a professional way. They can be holistic or specialist and

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enable specific nursing-management strategies to be employed. They improve standards of nursing care by promoting consistency of assessment criteria. Assessment tools are also cost‘Assessment tools can be used in every setting, in every effective because they enable efficient clinical speciality, and in every and effective use of resources aspect of nursing care.’ and help to determine appropriate equipment allocation. They result in proactive (rather than reactive) nursing care, minimise the occurrence of unrecognised risk factors, and reduce the duration of nursing care. Assessment tools can also be used for validation and auditing purposes, and are useful for protection against litigation. Research activity, education, and communication are all facilitated by assessment tools. Assessment tools can be used in every setting, in every clinical speciality, and in every aspect of nursing care. Assessment tools are especially useful: • on admission to establish a baseline; • when there has been a change in the situation; and • for validation and auditing purposes. All professional nurses who are members of the multidisciplinary healthcare team can use assessment tools. They improve nursing practice by promoting a transparent process, promoting teamwork, and providing consistency of assessment criteria.
Problems with assessment tools

Unfortunately, many nurses have a poor understanding of the nursing process and the vital role of assessment in that process. In particular, many nurses do not have a good understanding of the process of developing an assessment tool—research, development, implementation, analysis, and evaluation. These deficiencies lead to such problems as: • the use of assessment tools that do not cover all aspects of the clinical situation (thus leading to inconsistent or incomplete assessment and re-assessment);

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• poor understanding of the role of an assessment tool in the validation and auditing process; and • the use of tools with unproven validity and reliability in research projects.

Nursing-care plans
Nursing-care plans (NCPs) are written tools used by nurses to ensure that planned care is carried out after a resident’s needs have been identified. An NCP must be an ‘accessible, unambiguous, comparable and readable professional tool’ (Richmond 1997, ‘ … an accessible, p. 176). It enables planned care to be unambiguous, comparable and undertaken by nurses in a systematic, readable professional tool.’ measurable way and ‘focuses on the actions nurses must take to address the [resident’s] identified nursing diagnosis and meet the stated goals’ (Kozier, Erb & Olivieri 1991, p. 215). For more on NCPs, readers are referred to Chapter 4, page 45.

Progress notes
Once nursing care has been completed, it is important to revisit the NCP to identify if there has been any nursing care that has been different from that envisaged in the NCP and/or to identify new matters to be included in the NCP. A list of the issues should be made, and a decision taken as to whether to record these issues in the progress notes or to add them to the NCP. Short-term or one-off issues can be recorded in the progress notes. Ongoing issues should be added to the NCP. The additional entries (in the progress notes or the NCP) should be initialled and dated. In making entries in the progress notes, a list of the issues should first be made and the list should be prioritised from the most important to the least important. A record should then be made in the progress notes utilising the following format: • What is the issue? • What is the cause of the issue? • What action has been taken or planned to be taken?

239 A Systems Model for Documentation

• What is the outcome of any actions already undertaken? • Who needs to be informed of the changes that have occurred?

The next stage in the model being discussed in this chapter (see Figure 15.1, page 212) is assessment.

Auditing is the systematic analysis and evaluation of nursing documentation. Auditing provides feedback to management and nursing staff on how successful and relevant nursing documentation has been. Auditing is an essential part of a continuous improvement ‘Auditing is an essential part of a continuous improvement process.’ process. It ensures that current practice is in accordance with best practice and identifies improvements that might be required. It also identifies gaps in staff knowledge, thus assisting in the planning of nursing education and training. Auditing encourages ongoing collaboration among nursing staff and fosters professionalism. The auditing process begins with initiating an auditing plan, developing an auditing process, and developing an auditing tool. The important steps thereafter are: • evaluating audit-compliance risks; • developing a compliance plan; and • monitoring compliance plan results.
Evaluating audit-compliance risks

This step includes: (i) reviewing all documentation processes for efficiency and effectiveness; and (ii) evaluating and prioritising solutions for ‘at risk’ processes.
Developing a compliance plan

Included in this step are: (i) assigning nursing staff to specific responsibilities for major non-compliance/at risk processes; (ii) developing

or (ii) a comparison among units or sites within the organisation. (ii) conducting trials of new policies and processes. and due dates. (iii) scheduling periodic reviews of policies and processes. Benchmarking Benchmarking is an ongoing systematic process of rigorous comparison with best practice in other organisations. (ii) within the healthcare system. and complaints. (iii) ensuring functioning of incident tracking. and (iv) developing a system for documenting all decisions and adjustments to policies and processes. timelines. External benchmarking is conducted outside the organisation and aims to collect data: (i) within the aged-care industry. The key performance indicators provide a picture of the organisation. to identify gaps. . and (vi) establishing a process to resolve new issues. Contemporary progressive organisations are encouraged to seek out opportunities for external benchmarking to identify how they compare with their competitors. (iv) ensuring functioning of complaint tracking and resolution. risk management. Monitoring compliance plan results This step involves: (i) reviewing facilities.2 (page 241). and priority compliance. questions.240 Nursing Documentation a detailed work plan with allocated responsibilities. A suggested audit tool for NCPs is shown in Figure 15. or (iii) within different industries.’ framework for strategic and operational measurement. (v) monitoring results of staff communication and education. Benchmarking can be internal or external. Internal benchmarking is conducted within the organisation and aims to obtain data for: (i) trend analysis. Benchmarking uses key performance indicators to ensure that all areas of the organisation achieve their full potential in documentation. ‘Benchmarking uses key performance indicators to ensure that all areas and its future directions. of the organisation achieve their full Benchmarking is thus a potential in documentation. its performance. and to undertake effective planning and education.

2 Audit tool for NCPs AUTHORS’ CREATION .241 A Systems Model for Documentation NCP components Nursing problem/diagnosis Yes No Comments Is the nursing problem stated clearly? Is the cause of the problem stated? Are the resident’s signs and symptoms stated? Nursing goal Is there a resident-centred nursing goal? Is the goal realistic? Is the goal understandable? Is the goal measurable? Is the goal behavioural? Is the goal achievable? Nursing strategies Do the strategies reflect the goal that has been set? Do the strategies reflect resident-focused care? Do the strategies reflect current practice? Do the strategies reflect actual nursing actions? Do the strategies assist others to carry out actions? Do the strategies direct others to carry out nursing actions? Do the strategies support the resident in his or her endeavours to maintain/improve health status? Do the strategies acknowledge the resident’s strengths? Do the strategies encourage nurse-initiated/doctorinitiated care? Do the strategies encourage the inclusion of all possible nursing interventions? Figure 15.

1. .242 Nursing Documentation NCP components Nursing strategies Yes No Comments Do the strategies encourage inclusion of reassessment processes? Do the strategies encourage preventative as well as reactive measures? Do the strategies encourage quantifiable/specific language? Do the strategies reflect the skill level of the staff? Do the strategies reflect documentation requirements? Do the strategies reflect standards requirements? Evaluation Does the evaluation reflect what is to be evaluated? Does the evaluation reflect when it is to be evaluated and diarised? Does the evaluation reflect how it is to be evaluated? Does the evaluation reflect who is going to do the evaluation? Does the evaluation reflect what is to be recorded in the progress notes? Does the evaluation reflect the system for follow-up and ongoing review? Figure 15. page 212).’ conference presentations. Nurses should be encouraged to share their documentation experiences ‘Nurses should be encouraged and achievements with to share their documentation colleagues in the industry experiences and achievements with through journal articles and colleagues in the industry.2 Audit tool for NCPs (continued) Publishing The final step in the model being discussed in this chapter is publishing (see Figure 15.

it is important to be passionate about the aspect of documentation to be presented. Conference presentation In making a conference presentation. it should not be assumed that every reader is an expert on the topic. simple. However. It is permissible to criticise the work of others. The analysis should be sharpened in various drafts of the article. However. nurses should contact the publisher and seek details of the journal’s preferred format. and concise. but the author should not become obsessive about small details. Once the material is collated. A clear rationale for the importance of the subject should be offered. . All key terms should be defined. It is advisable to ask others to criticise the article before it is submitted. the full presentation should be practised—with special attention to getting the timing correct. Nurses should realise that authors often have to be persistent if they are to get work published in journals. However. Notes should be well organised and readily available at all times during the presentation. Any slides or other audiovisual materials should be of good quality. and submission processes. it should be tested before the actual presentation. it is important to cite all references and acknowledge the work of others. Software that supports a conference presentation (such as PowerPoint) should be utilised. the presentation can be lightened by the inclusion of humorous comments. In commenting on the work of others. style. Fair criticism should be accepted constructively. notes should be used as a prompt—rather than reading directly from them. but this criticism should never be derogatory or insulting. The presenter should undertake thorough research and present the subject in a clear and coherent fashion. If an overhead projector or other audiovisual aid is to be used.243 A Systems Model for Documentation Journal articles In preparing a journal article. It is important to establish the nature of the audience and prepare the article with that readership in mind. and the presentation should move from the main point to less important points.

a summary of the key issues and recommendations should be offered. A professional documentation system entails many stages. ensures that all areas of the organisation are committed to ‘A professional level of documentation quality documentation. and communication within the organisation is essential. The presentation must be completed within the allocated time. such as the one discussed in this chapter. and the audience should always be thanked for their attendance and attention. Conclusion A systematic approach to documentation ensures efficiency and effectiveness in the management of residents and promotes best practice within the organisation. the presenter must ensure that he or she is well versed in the subject and able to accommodate audience comments and questions. . It is that is accessible to all … ensures best essential that all staff members care of residents and protection of the understand their documentation organisation’s funding status.’ requirements if fragmentation is to be avoided. The presenter should not move around too much—unless audience involvement is expected or a roving microphone is available. In concluding the presentation. If audience participation is expected. If a microphone is available it should be used correctly and effectively. A systematic approach. Any such questions or comments should be listened to with care and courtesy. A professional level of documentation that is accessible to all members of the multidisciplinary healthcare team ensures best care of residents and protection of the organisation’s funding status.244 Nursing Documentation It is important to speak clearly and at an appropriate volume.



Appendices .


Mrs Green had severe arthritis with limited mobility and limited manual dexterity. passing of hard stools. She always had a feeling of incomplete emptying. a 72-year-old resident of an aged-care facility.Appendix 1 Faecal Incontinence Janette Williams Case study Mrs Green Presenting problem and history Mrs Green. (continued) . There was no history of recent surgery. She stated she had not had her bowels open properly for several days and was having leakage of faeces— although she was unaware when this was happening. She was classified as requiring a high level of care. She had no pain but frequently felt ‘bloated’. Mrs Green had a long history of constipation. complained of severe constipation and feeling bloated. and straining to open her bowels. but Mrs Green had had two total knee replacements and one total hip replacement in the past 10 years.

• fluid intake—poor (4–5 cups of tea per day). able to chew. slightly red skin. faeces around anus. Problem Chronic constipation with overflow incontinence . difficulty in reaching the toilet easily. • activity and exercise—reduced (due to arthritis). two external haemorrhoids. difficulty in removing clothing easily. • mobility—poor. and • abdominal X-ray—faeces in the descending colon and rectum. hard faeces in the rectum. • rectal examination—weakened anal tone with inadequate sphincter contraction. • abdominal palpation—a mass of hard faeces in the lower descending colon. • manual dexterity—poor. • medications—paracetamol (2 tablets 4 times a day) for pain.250 Nursing Documentation (continued) Physical examination and investigations The physical examination of Mrs Green revealed: • condition of mouth—well-fitting dentures. Coloxyl with Senna 2–3 daily (for more than three years). one enlarged internal haemorrhoid. and • other factors—toilet seat not high enough for Mrs Green to sit in a comfortable position to have her bowels open. verapamil for blood pressure. Nurse’s assessment The nurse’s assessment of Mrs Green revealed: • diet—insufficient fruit and vegetables. • inspection of perineum—no skin tags.

Assessment tools for constipation In general. • cognitive state. • volume. • bowel diary: • frequency. • previous bowel surgery. • colour. • diet and fluids. • inflammatory diseases (such as irritable bowel syndrome). • toilet facilities. assessment tools for constipation should address the following: • recent medical history that might aggravate risk of constipation. • mouth and dentures. nurses should be requested to keep a bowel chart for one week. • episodes of incontinence. • degree of incontinence. • volume of faeces. • previous bowel habits.251 Appendix 1 Faecal Incontinence Documentation for this case study Bowel chart In the case of Mrs Green. • mobility and manual dexterity. . Documentation on such a bowel chart should include: • frequency of defaecation. • consistency of faeces. • colour of faeces. • consistency. and • faecal smearing. • medications and use of laxatives. • fluid and food chart.

• perineum (skin tags. • other investigation: • abdominal X-ray. faeces in rectum. faeces around anus. • Clear the constipation with two glycerine suppositories and a Microlax enema. and • colonoscopy (if appropriate). . Management plan A written management plan for Mrs Green was drawn up. and fruits). • abdominal palpation (for presence of hard faeces in colon). • normal. • Work with a physiotherapist to assist with mobility and gentle exercise program. and • rectal examination (anal tone. • Increase fluids to 6–8 glasses per day—including prune or pear juice daily (to assist with peristalsis). • Increase fibre in diet. vegetables. • Encourage regular bowel routine by going to the toilet at a regular time every second day. beans. • Discuss with Mrs Green food she likes—to assist with the diet changes (such as wholemeal bread.252 Nursing Documentation • sensation of desire to defaecate: • absent. This included the following. tenderness). going to the toilet after a meal such as breakfast). Make use of the gastro-colic reflex (that is. skin condition). • urgent. fissures. • physical examination. • Reduce caffeine intake. • unaware. haemorrhoids.

• Instruct Mrs Green to maintain bowel diary to: • monitor for faecal incontinence. • With the assistance of a nurse. place her feet on a footstool to bring her knees above her hips to reduce the need to strain. and • instruct Mrs Green to lean forward on the toilet seat (to reduce the need to strain). and • to help prevent further constipation with overflow. and • slowly reducing the number of Colyxl and Senna tablets and replacing with bulking agents (such as Normafibre or Movicol). but with emphasis on anal sphincter). • Review management plan after one month. • Instruct Mrs Green re how to strengthen her anal sphincter tone by performing anal sphincter exercises (same as pelvic-floor exercises. . • Ensure Mrs Green drinks 4–6 glasses of fluid per day to avoid using irritant laxatives (except intermittently). • analgesic alternatives to reduce the number of paracetamol tablets taken each day. • Toileting arrangements: • place toilet seat raiser on the toilet to enable Mrs Green to sit comfortably on the toilet. ensure that Mrs Green is able to attend to personal hygiene following bowel action (to prevent skin excoriation). • if she is able.253 Appendix 1 Faecal Incontinence • Discuss medication regimen with medical officer with a view to: • changing verapamil to another medication that does not have side-effect of constipation.


confusion.Appendix 2 Behavioural Management Robyn Daskein Case study Mrs Robinson Presenting problem and history Mrs Robinson was an 84-year-old resident of an aged-care facility who had been assessed as requiring high-care placement. (continued) . Mrs Robinson had been suffering from shingles for the past two months. and verbal behavioural problems (calling out and repetitive communication). The psychogeriatric team had developed a behavioural modification plan that included time management intervals to manage her inappropriate communication episodes. The doctor had ordered calamine lotion and paracetamol 2 tablets 4-hourly if required. The doctor had suggested that Mrs Robinson’s calling-out was most probably due to the pain of shingles. The psychogeriatrician’s assessment was that Mrs Robinson had mild dementia.

• sleep assessment—called out in her sleep. repeats requests). feelings of loneliness. Mrs Robinson does not always realise where she is. continually asking for the same thing. periods of withdrawal. takes her medication uncrushed. repeats requests time and again. a usual sleep pattern of 6–8 hours of sleep each night. • pain assessment (verbal and non-verbal)—moderate pain. a different issue every night. (continued) . sight is satisfactory. buzzed repeatedly (buzzing starting again as soon as staff members left the room). on a continence program. • skin assessment—skin dry and thin. and other inappropriate behaviours were more prominent in the evening and between 0100 hrs and 0400 hrs. Relevant investigation A CAT scan of the brain had revealed a lesion (?brain tumour ?CVA) over mobility area of cerebral cortex. • nursing behaviour charting assessment—over a 7-day period demonstrated that mild comprehension difficulties. repeats the same words over and over. shingles lesions on the upper right abdominal quadrant (persistently scratched by resident). • activities of daily living—two staff members are required to assist with Mrs Robinson’s activities of daily living.256 Nursing Documentation (continued) A medication review by the clinical pharmacist had identified low dosage of pain medication as a problem. and had suggested a review of Mrs Robinson’s pain regimen. can manage her meals independently. deaf in both ears. • environmental assessment—room at the end of the corridor where she had a single room and shared an ensuite. continually buzzing for assistance (and when attended. confusion. settled at 2100 hrs following a cup of tea. Nursing assessment Nursing assessment of Mrs Robinson revealed: • communication—bouts of confusion. trends in pain assessment indicated that uncontrolled pain was a contributing factor in the pattern of calling-out.

Problem Interventions Outcomes Ineffective communication Establish trust.257 Appendix 2 Behavioural Management (continued) • social and cultural assessment—a strong family background. Problem Verbal behavioural problems—calling out and repetitive communication. a nursing-care plan for this problem was drawn up in the usual way in three columns. be reliable Do not argue with Mrs Robinson Mrs Robinson will be able to communicate her needs more effectively . the centre of attention in her family circle. had been active in community activities. The beginning of the plan is shown below. her behaviour was the same when she was on bus outings. Mrs Robinson constantly called out if left unattended. • diversional therapist program—while in activities with the diversional therapist. major personal losses included the death of her son (when she was 60 years old) and the death of her husband (one month ago). two daughters visited regularly (Mrs Robinson enjoyed communicating with them). Documentation for this case study Nursing care plan On the basis of the above case history.

• Clarify what she intended to say to ensure correct communication. keep your word. and • buzzing constantly.258 Nursing Documentation The full information on the nursing care plan was as follows. • Face Mrs Robinson and observe for changes in body language (non-verbal language). . As assessed by: • behavioural assessment—mild comprehension problems and mild depression. • calling out. and • medical condition. • Offer reassurance and comforting words. • Encourage Mrs Robinson to express her fears. • One nurse each shift to care for her and implement the behavioural management strategies as per program. • Maintain adherence to the behavioural management time program. • social history—indicates Mrs Robinson is used to having people around her and being the centre of attention. be reliable. Column 2 Interventions and actions • Establish trust. Column 1 Problem Ineffective communication (more prominent in the evening and nighttime): • confusion. • Use reflective listening skills when attending to Mrs Robinson. • repetitive communication. • Do not argue with Mrs Robinson or tell her she has already told you that. Related to: • effects of social isolation. if you say you will be back.

• Monitor and evaluate the effects of behavioural management interventions and pain interventions. • Observe for signs of depression and withdrawal. interact in groups. • Respond empathically to the emotional tone of her statements. • Use picture family boards and tapes of family interaction to reduce her isolation (as per activities program or when attending to her care). be able to communicate her needs more effectively. • Offer her a cup of tea at settling time and when she is awake during the night. • Include Mrs Robinson in the volunteer program in the evening when her calling out and buzzing is most prominent. • Review Mrs Robinson’s behavioural assessment regularly and frequently to identify effective interventions. and participate in group conversations. and behavioural modification program. psychogeriatric team. • Move her room (with consultation) closer to the nurses’ station to provide company and visual comfort.259 Appendix 2 Behavioural Management • Offer an alternative word and wait for a signal from her as to appropriate selection. • Include Mrs Robinson when going on outings in the bus. Column 3 Outcome Mrs Robinson will. • Case conference regularly and frequently in consultation with her daughters. skin condition treatment. • Provide proactive and appropriate non-drug pain-management interventions. and doctor to review the outcomes of her pain management. . to the best of her cognitive ability. • Record triggers and outcomes of interventions.


• hypertension. Because her family was unable to care for her. Her interests included bridge. and gardening. She had retired many years previously after working in a cigarette and sweets shop in the city. Her medical history included: • diabetes (type 2) for 15 years.Appendix 3 Diabetes Victoria Stevenson Case study Mrs Martin Presenting problem and history Mrs Martin was a 74-year-old widow with two sons and a daughter. • coronary artery bypass surgery (10 years previously). embroidery. (continued) . Mrs Martin had resided in a nursing home for four years. She was a very tidy and independent lady who liked things done in a certain way at the right time. Mrs Martin was an ex-smoker who ‘liked a glass of champagne to see in the New Year’. This included her meals.

Mrs Martin’s family history revealed that her mother had diabetes and had died from an infection following her second leg amputation. aspirin 100 mg daily. Her blood glucose levels were checked every morning. and • painful right knee (caused by a fall years ago). Mrs Martin’s medications were glibenclamide 5 mg in the morning. metformin 500 mg in the morning. Mrs Martin’s father had died of a stroke.8%—indicating effective diabetes control in the previous 2–3 months. Over some weeks these results had begun to rise from 5–12 mmol/L to 14–19 mmol/L. Mrs Martin’s renal function was satisfactory. Her supper was unchanged—one chocolate after-dinner mint with a cup of tea. Although she had usually not been keen on afternoon tea. Another recent change to her usual routine was that Mrs Martin had occasionally fallen asleep after breakfast and had missed the beginning of her physiotherapy session. While in hospital. Problem Appears to have unstable blood glucose levels with nocturnal hypoglycaemia. Her meals remained unchanged and she always showed annoyance if there was any fat on the meat. Mrs Martin had recently begun to arrive first in the diningroom and was heard to complain of being particularly hungry and dizzy. The hunger and dizziness were corrected with extra scones. She had recently been hospitalised for a left fractured femur. Mrs Martin had needed assistance to change her nightie (due to night sweats) and had been surprised each morning to note the change of clothes. Her diabetes regimen had been increased recently while she was in hospital. and perindopril 2 mg daily. .262 Nursing Documentation (continued) • reduced vision. The night staff had also documented several episodes of unexplained restless nights. her diabetes had become difficult to control and had required insulin for one week. and a recent HbA1c was 6.

Discussion of the nursing diagnosis The nursing diagnosis of hypoglycaemia was based on the nocturnal sweats and restless sleep. her elevated morning blood glucose levels (14–19 mmol/L) confirmed that this was happening.5–3. Nursing diagnosis The nursing diagnosis was nocturnal hypoglycaemia as evidenced by nocturnal sweats and restless sleep. nurses increased the frequency of blood glucose testing and recording. Rebound hyperglycaemia can occur in this situation. The likely cause of Mrs Martin’s nocturnal hypoglycaemia was excessive diabetes medication. The results were as follows: • fasting levels: 14–19 mmol/L • pre-lunch: 4–5 mmol/L • pre-dinner: 4–6 mmol/L • pre-supper: 3.9 mmol/L at night confirmed this nursing diagnosis. The symptoms of lightheadedness and hunger in the afternoon indicated that she was also suffering from hypoglycaemia at that time of .5–3.9 mmol/L 2. In Mrs Martin’s case. Overnight hypoglycaemia can also produce unpleasant dreams and waking with a headache. The blood glucose level of 2. Blood glucose charting In response to the above.263 Appendix 3 Diabetes Documentation for this case study 1. and the stronger medication regimen adopted in hospital was no longer appropriate. The rebound high sugar level is due to stress hormones being released—causing glycogen (stored glucose) to be released from the liver into the bloodstream to correct the nocturnal low blood sugar.5 mmol/L • with night sweats: 2. Her falling asleep after breakfast was most likely due to the effect of the high sugars and (perhaps) a disturbance in her sleep pattern.0–4. Mrs Martin had now recovered from her hip surgery.

Her recent attendance at afternoon tea and her desire for extra scones was further evidence for this. Blood glucose testing • Test pre-meal and bedtime until diabetes becomes stable again (5–12 mmol/L). . Testing the blood glucose level before afternoon tea might have shown a level below 3. Management plan The following plan of management was drawn up and documented. • Do a blood glucose level. • She follows a diet of high complex carbohydrate. • Encourage water or low-calorie cordial with her meals. • She likes an after-dinner mint at supper. • If pre-supper blood glucose level is 6 mmol/L (or lower). low sugar. low fat. Medication • Medication is to be to be taken with breakfast and (if required) with the evening meal.264 Nursing Documentation the day (although blood glucose testing was not done at that time). Treatment of hypoglycaemia • If conscious: • 7 jelly beans (chewed) or 1 glass of normal soft drink or 3 teaspoons sugar in half a glass of water. • She takes sandwiches to her diabetes outpatient appointments.5 mmol/L. Nutrition and hydration • Mrs Martin likes to eat on time. • Report any blood glucose level below 5 mmol/L. 3. • Ask medical staff to review medication. and low salt. give a few biscuits or a glass of milk in addition to her chocolate afterdinner mint.

Sleep pattern • • • • Undertake a sleep assessment. sandwich. it is important to have regular and frequent staffeducation sessions. clear airway. 4. Do a repeat blood glucose level within 15 minutes.265 Appendix 3 Diabetes Follow with biscuits. or meal (if due). • Check Mrs Martin regularly and frequently throughout the night for change in sleep pattern. call an ambulance. Encourage staff to attend these sessions. • Normal soft drink (not low-calorie drinks) to be located in a convenient area. • Jelly beans are to left in her bedside drawer (because she is at risk of hypoglycaemia). Safety and risk management • Assist at all times (because of her history of falls). • Do a blood glucose level and stay with her. milk. Note that any food for hypoglycaemia is in addition to her usual next meal. • Ask medical staff to review medication. and encourage staff members to read these. . Make relevant journal articles and easy-to-follow guidelines available in the facility. Staff education In a case such as this. • If unconscious: • Roll onto side.


Appendix 4 Nausea Robyn Millership Case study Mrs Green Presenting problem and history Mrs Green. She was grieving the loss of her husband of 54 years and of her loved home. Her past medical history included severe arthritis. and borderline renal function. aged 82. She missed the garden setting and the large living area of four bedrooms. She and her husband had built their home and had raised five children in it. and lounge-room. had moved into an aged-care facility two months after her husband had died. Mrs Green had great difficulty settling into her new surroundings. obesity. For the past three weeks Mrs Green had been complaining of intermittent nausea. kitchen. ischaemic heart disease. including chocolate biscuits. She had now begun to refuse (continued) . It also occurred on waking in the morning. dining-room. This was precipitated by the smell of food as the meals were served. She had always had a very good appetite—enjoying her meals and frequent treats.

They have never known their mother to be ‘off her food’. 6 hourly. The nursing staff discussed the possible causes of her nausea with the visiting doctor. as required. She was not even eating her favourite biscuits. other symptoms. . Problem Nausea and reduced food intake. as required. 6 hourly. and she became tired and lethargic.268 Nursing Documentation (continued) food because she was afraid that she would vomit. was prescribed. Her family had become worried that she would ‘fade away’. Treatment Mrs Green was prescribed oral metoclopramide (Maxolon) 10 mg. food intake. It was agreed that an objective measurement and description of the nausea was required. and medication. The locum doctor was notified and a telephone order for oral prochlorperazine (Stemetil) 25 mg. Mrs Green’s dietary intake reduced further. An assessment tool was used. After several doses of metoclopramide she was still complaining of nausea. This assessment tool recorded the severity of nausea.

A suitable nausea assessment tool is shown on page 270. or urinary symptoms (frequency or dysuria). • time sequence of the nausea. Assessment should therefore include documentation of: • onset and pattern of nausea—such as whether the nausea is related to taking medications. together with any associated symptoms. thirst. movement. The use of an assessment tool provides a clear picture of the issues and assists in determining the treatment. be carefully documented. A history of the onset and pattern of the nausea should be obtained. hiccoughs. meals. sore mouth. Antiemetics should be selected on the basis of presenting symptoms. • haloperidol for general nausea and anxiety. Such an assessment tool should incorporate: • a visual analogue scale. of course. pain on swallowing. For example: • metoclopramide for gastric stasis. • usual bowel function pattern—including constipation or diarrhoea. • chlorpromazine for hiccoughs. Treatment The treatment regimen should.269 Appendix 4 Nausea Documentation for this case study Assessment The key to successful management of nausea is thorough assessment. • action taken. . or the sight or smell of food. heartburn. and • outcome. and • cyclizine for motion sickness. • associated symptoms—such as epigastric pain.

haloperidol 2 5 2 5 3 3 2 1 1 0 0 . haloperidol metoclopramide. 5 2. haloperidol metoclopramide metoclopramide. 5 2. haloperidol metoclopramide. Constipation 4. 5 2. 7 0 0 metoclopramide prochlorperazine metoclopramide prochlorperazine metoclopramide metoclopramide metoclopramide. 5 2. 5 2. Anxiety 3. 4. 7 2. 7 2.270 Nursing Documentation Nausea Assessment Tool Visual analogue scale 1 → 2 → 3 → → 4 → 5 → 6 → 7 → → 8 → 9 → 10 mild moderate severe Key to associated features 1. Lethargy 5. 4. Before food 6. After medication Date Time Score Associated features Intervention Outcome score 01 Dec 2006 01 Dec 2006 01 Dec 2006 02 Dec 2006 02 Dec 2006 02 Dec 2006 03 Dec 2006 03 Dec 2006 03 Dec 2006 04 Dec 2006 04 Dec 2006 0900 1400 1750 0600 1130 1730 0600 1200 1800 0600 1200 7 6 7 8 8 5 4 3 2 0 0 2. Pain 2. 4. 5 2. After food 7.

It was therefore decided to use oral metoclopramide 10 mg 6-hourly strictly during the day. • associated with anxiety. Review after intervention Regular and frequent review after any intervention is vital if the effect of the intervention is to be accurately assessed. and • not responding to prochlorperazine. For example: • steroids for nausea related to raised intracranial pressure.5 mg twice daily was added. or malignancy. A written record helps to establish any pattern of response to various medications or other interventions. .271 Appendix 4 Nausea Before changing to another antiemetic. Mrs Green talked about feeling nauseated for weeks after the death of her husband. This leads to a more systematic management plan and facilitates control of this debilitating problem. the chosen antiemetic should always be used at a dosage within its therapeutic range. hypercalcaemia. The underlying cause of the nausea should be treated if possible. entering into conversation with other residents. Combination therapy might be necessary for multiple causes of nausea. After two days of the combined regimen. Mrs Green was eating her meals. and • appropriate medication and/or counselling for anxiety. She also acknowledged her feelings of loss and grief over the move from her family home. Because anxiety was an associated feature. Outcome After two days the assessment tool record (see page 270) revealed that Mrs Green’s nausea was: • worse before meals. and generally feeling much better. • ranitidine for gastric irritation. In conversation with her family and other residents. • aperients for constipation. oral haloperidol 0.

. both the metoclopramide and haloperidol were ceased—with no return of nausea.272 Nursing Documentation Three weeks after this episode.

her doctor had arranged for Mrs North to be admitted to an aged-care facility. However. She was obese—weighing 114 kg. she had many supportive friends and neighbours and had initially managed well. following recent rapid deterioration. Mrs North’s medical problems included diabetes. Mrs North was 75 years old. which had been treated with surgery (including a colostomy). radiation. hypertension. and chemotherapy. and congestive cardiac failure with pitting oedema. although she was only 150 cm tall. Mrs North’s ovarian cancer had led to bowel obstruction.Appendix 5 Stomal Care Heather Hill Case study Mrs North Presenting problem and history Mrs North had been diagnosed as having ovarian cancer two years after her husband of 50 years had died of bladder cancer. Although she had no family. Mrs North’s stomal problems were that her appliance had been leaking for three days and the nursing staff had been taping pads around the area (continued) .

An extra wide hernia belt was fitted to provide some support and comfort. odour control. . With her change in shape. and emotional status. The odour from the leakage. As a result of these measures. A diagrammatic chart. Stomal deodorant tablets or fluid in the appliance were recommended.274 Nursing Documentation (continued) to absorb the drainage.5 cm). Suitable odour-absorbent substances were recommended for Mrs North’s room. a new pouching procedure. loosening the wafer. Stomal nursing assessment and management On examination her abdomen was huge as a result of ascites. her abdomen had been leaking fluid. A large flexible absorbent hydrocolloid sheet had been applied to help draw the ascitic fluid away from the skin. The stoma mucosa was pink and healthy. and contact telephone number were left with nursing staff to facilitate care on each shift. detailed written instructions. and odour control. Because of the ascites. and vaginal discharge was ‘terrible’. leakage. and a parastomal hernia. The nursing staff and Mrs North were instructed on skin care. tumour. Mrs North’s colostomy had become flush with the skin and oval in shape (5 cm x 2. hernia belt application.5 cm. and to call if there were any further unmanageable issues. Staff members were asked to document any alterations to skin. The excoriation radiated out beyond the appliance by 1. Mrs North’s skin was excoriated from leaking faecal matter and the tape that had been applied to keep the pad in place. urinary incontinence. Mrs North’s remaining two months of life were trouble-free in terms of stomal problems. stoma. A new template was made to fit the stoma.

and is not necessarily a problem. Alteration in colour might indicate impaired blood supply. remover wipes. psychological. In addition. and medical status should be noted. Large amounts of blood loss or blood coming from inside the stoma should be reviewed by a specialist or stomal-therapy nurse. (iii) whether a closed end or drainable. Bleeding from the surface of the stoma often occurs during cleaning. Nurses should check that peristaltic movement of the stoma is normal. Note what is being used and why (pastes. An accurate measurement can be obtained by tracing the size onto a clear acetate measuring guide (which are provided free of charge by ostomy companies). State: (i) the make. (ii) whether two-piece or one-piece. The stoma should ideally be raised above the skin approximately 1 cm.275 Appendix 5 Stomal Care Documentation for this case study Efficient stomal management depends on precise reporting and the use of consistent terminology. Serial photographs provide objective evaluation of progress. the following should be documented. Should be pink-to-red in colour. Recognition of contour variations can help to indicate where future problems might occur with appliances. a piece of clear plastic can be used to make a template. With respect to the stoma itself. Alternatively. Size and shape differs with the type of stoma. Stomal appearance Location Colour Bleeding Size and shape Contour Equipment Appliance (bag/pouch) Accessories (continued) . deodorants. covers). protective wipes. a photograph of the stoma and peristomal skin is the best documentation. (iv) whether with or without filter. powders. Item Matters to be documented Document position on body and if any associated problems (such as the stoma being in a skin fold). The resident’s overall physical.

Have client reviewed by medical officer or stomal-therapy nurse. and appearance. and descriptive outcomes. Document reports. and descriptive outcomes. Have client reviewed by medical officer or stomal-therapy nurse. shape. treatment. and appearance. Report urine colour. Document reports. treatment. If a person with an ileostomy has no faecal output. Document reports. Output Faeces Flatus Odour Urinary stoma output Abnormalities Stenosis Retraction Herniation Prolapse Mucosal lesions or ulcers (continued) . Have client reviewed by medical officer or stomal-therapy nurse. and appearance. Note consistency and volume. shape. and descriptive outcomes. Document size. but might indicate infection. State whether present or not. shape. consider dietary modification. and appearance. Document reports. Note if any constipation is rare in people with stomas. No faecal output can indicate a blockage. Note if any diarrhoea (but be aware that this can be overflow from constipation). shape. and appearance. Have client reviewed by medical officer or stomal-therapy nurse. and asparagus). treatment. but can occasionally happen with a sigmoid colostomy. Document reports. Document size. Report whether mucus present (this is normal). Diarrhoea in the elderly should not be ignored because dehydration and electrolyte imbalance can occur quickly and might require urgent treatment. If flatus and/or odour are excessive. and descriptive outcomes. This can caused by foods (especially fish. treatment. eggs. treatment. shape. Document size. Have client reviewed by medical officer or stomal-therapy nurse. Should be obvious only when changing or emptying an appliance.276 Nursing Documentation (continued) Item Matters to be documented Note colour (and be aware that bright-red faeces can result from food such as beetroot). and descriptive outcomes. Document size. Document size. This varies with the type of stoma and position in the bowel. report immediately and seek help from a stomal-therapy nurse or specialist (the person may have a blockage). Report whether odour present.

this indicates a problem. the red flush usually fades within minutes. Have client reviewed by medical officer or stomal-therapy nurse. Document reports. and descriptive outcomes. Document reports. Have client reviewed by medical officer or stomal-therapy nurse. Document size. Have client reviewed by medical officer or stomal-therapy nurse. and appearance. and descriptive outcomes. treatment. treatment. Document treatment and outcomes. Document as appropriate. Cellulitis. and descriptive outcomes. Document reports. Document treatment and outcomes. . and appearance. heat. treatment. Document reports. shape. swelling Rashes Lesions/ulcers Any other changes Perineal wound Persistent drainage Odour Skin conditions Document and seek advice. and appearance. Document and seek advice.277 Appendix 5 Stomal Care (continued) Item Matters to be documented Document size. Document size. Psychological status Perceptions Feelings Thoughts Document as appropriate. and descriptive outcomes. Document and seek advice. shape. Document size. Abnormalities Oedema or swelling Skin condition Colour When an appliance is removed. shape. treatment. Have client reviewed by medical officer or stomal-therapy nurse. Have client reviewed by medical officer or stomal-therapy nurse. Document reports. shape. and descriptive outcomes. and appearance. Document as appropriate. and appearance. Document size. Document treatment and outcomes. treatment. shape. If the skin remains an ‘angry’ red colour.


In the following weeks the wound continued to be dressed twice a week with paraffin-impregnated gauze and a non-adherent dressing.Appendix 6 Leg Ulcer Management Sue Templeton Case study Mrs Edwards Presenting problem and history Mrs Edwards was an 82-year-old woman with a history of obesity. At the time of the injury.5 cm wound. Mrs Edwards had sustained a skin tear to her right lower leg from a wheelchair footplate. (continued) . hypertension. The wound had been redressed daily for the first week. the wound had been cleansed with saline and dressed with paraffin-impregnated gauze. a nonadherent dressing. The skin had been completely removed—resulting in a 3 cm x 2. stripping of varicose veins (35 years ago). during which time there continued to be a moderate amount of haemoserous exudate. osteoarthritis. and five pregnancies. and crepe bandage.

Mrs Edwards was commenced on a program of graduated compression therapy using a four-layer bandage system. and limited mobility. the wound size had increased to 4 cm x 3 cm and the base of the wound had become sloughy. the oedema was controlled. Mrs Edwards was then fitted for a pair of compression stockings for ongoing control of her venous insufficiency and to ensure that skin integrity was maintained. Within 12 weeks of continuous. This corrects venous insufficiency through promotion of venous return. This was confirmed by use of the leg-ulcer assessment tool (see page 282). multiple pregnancies. Ongoing documentation of the wound demonstrated that. Control of venous insufficiency is required for healing to progress. . oedematous legs. In particular. She was also encouraged to elevate her legs when sitting. Graduated compression therapy is the recognised treatment for venous ulcers. varicose veins.280 Nursing Documentation (continued) A month after the initial injury. Nursing assessment Mrs Edwards’ wound should now be classified and treated as a chronic leg ulcer because it has not progressed along the expected wound healing processes to produce anatomical integrity. a wound between the knee and ankle that is unhealed beyond four weeks should be classified as a chronic leg ulcer. graduated compression therapy the wound had healed. Diagnosis and management The cause of delayed healing is likely to be venous insufficiency due to obesity. Within four weeks the wound had halved in size and the wound base was no longer sloughy. within two weeks.

Leg-ulcer assessment tool Specific assessment tools can identify underlying pathologies that are impeding healing and can assist in determining the aetiology of a leg ulcer. This documented assessment must be used to inform. • allows the practitioner to record a comprehensive baseline assessment of a leg ulcer. and • to provide a reference from which wound progress can be monitored. such a tool: • provides prompts to identify the aetiology of a leg ulcer. and monitor appropriate wound interventions.281 Appendix 6 Leg Ulcer Management Documentation for this case study General assessment A thorough assessment is necessary: • to ensure that the aetiology of the wound is correctly identified. . In particular. • to identify factors that might impair healing. and • provides links to organisational guidelines that promote evidencebased practice to ensure that interventions will result in optimal client outcomes. plan. A leg-ulcer assessment tool (see page 282) provides systematic documentation and can assist the relatively inexperienced practitioner to determine wound aetiology and appropriate management.

white skin Stasis eczema Limb may be warm Oedema present.......O.….. especially after standing/sitting for long periods Pain quality Usually at dressing changes When oedema is severe In the presence of infection Pain level (circle)               Possible indicators of arterial insufficiency Ulcer Small deep.... GP/Consultant: Dr Taylor Signature (print name also): Sue Templeton CNC  Left leg  Right leg Indicate the site of the ulcer(s) on the appropriate diagram with ‘X’.. Condition of ulcer  Necrotic (black)  Sloughy (yellow)  Low exudate  Stage 2  Epithelialising (pink)  Infected (green)  High exudate  Stage 3  Granulating (red)  Stage 4 The pattern of ticks may provide an indication of possible contributing risk factors relating to venous or arterial disease. thickened toenails Thin..: Female Mrs Edwards Glenda 14/07/1920 UR NUMBER 123456 (Affix sticker) Hospital/Clinic: ……………….....B.. however there may be other causative factors...... number each one..……. If more than one.. possibly multiple ulcers Well defined.. dry skin Absence of hair growth Limb may be cool Oedema absent.. ‘punched out’ margins Rapid progression Dorsum of foot/toes/lateral leg Associated leg changes Foot dusky/pale when elevated > 3 seconds capillary refill time Poor quality... shiny... Possible indicators of venous hypertension Ulcer Large....282 Nursing Documentation ROYAL DISTRICT NURSING SERVICE OF SA INC LEG ULCER ASSESSMENT TOOL Allergies/Sensitivities: Nil Known Date of assessment: 11/09/2002 Ulcer site(s) GENDER: TITLE: SURNAME: FIRST NAME: D.... or may be present when limb inactive or dependent Pain quality Aggravated by exercise May be worse when leg elevated Relieved when leg in dependent position               (no pain) 0 1  3 4 5 6 7 8 (worst pain imaginable) 9 10 . shallow ulcer Poorly defined margins Slow progress Gaiter area: medial/lateral malleolus Associated leg changes Reddish/brown skin pigmentation Dilated and or tortuous superficial veins Vein distention of medial foot Thin..

.….……….. Diagram to scale of ulcer(s) size 1 box= 1cm2 PUBLISHED WITH PERMISSION OF ROYAL DISTRICT NURSING SERVICE... liaise with CNC or Advanced Wound Specialist.….. SOUTH AUSTRALIA ...….3 mmol Present  Present  Doppler assessment Doppler assessment in the past 12 months? Yes  No  Unknown  If yes... Observations Pedal pulses Blood pressure 140/80 Left leg Right leg Absent  Absent  Blood Glucose Reading 5. Doppler assessment should be carried out following assessment of all other factors and only by appropriately trained staff who have completed the Doppler Competencies and attended skills training..66(A) –Leg Ulcer Management)  Venous  Arterial  Mixed  Other Compression therapy is indicated for ulcers assessed as venous aetiology. Date performed ……….0 Date of doppler assessment 12/09/2002 Signature (print name also) Sue Templeton CNC Aetiology of ulcer assessed as: (Refer Nursing Practice Manual 2... Referral to a vascular specialist is recommended for ulcers of mixed or arterial aetiology.… ABPI …….CP. Where aetiology is unclear...… By whom ………………….………...283 Appendix 6 Leg Ulcer Management Possible indicators of venous hypertension Medical history Deep vein thrombosis Pulmonary emboli Phlebitis Varicose veins Previous trauma to leg(s) Previous surgery to leg(s) Obesity        Possible indicators of arterial insufficiency Medical history Arteriosclerosis Hypertension Angina/myocardial infarction Cerebrovascular accident/TIA Smoking Diabetes mellitus       Other conditions that may delay healing Malignancy Skin cancers Rheumatoid arthritis  Connective tissue disease   Immune deficiency   Bowel disease/Malabsorption  Other ……………………………………………………………………………………………………….....0 Right Brachial 140 Dorsalis Pedis 135 Posterior Tibial 140 ABPI 1. Doppler range Left Brachial 140 Dorsalis Pedis 140 Posterior Tibial 135 ABPI 1. Ulcers of mixed aetiology must be assessed by Doppler prior to instigation of compression. Medications that may affect healing …………………………………………………………………….


Appendix 7 PEG Nutrition Patsy Montgomery Case study Mrs Smith Presenting problem and history Mrs Smith was an 83-year-old woman who had lived at home for 12 months after suffering a cerebrovascular accident (CVA). The Yport connector at the end of the tube was leaking. (continued) . The life of such a tube is approximately 12 months. Video fluoroscopy undertaken in hospital had indicated an inability to swallow and an inadequate gag reflex. A percutaneous endoscopic gastrostomy (PEG) tube had been inserted 10 days after her CVA. The tube was very long and made of a medical silicon material. Mrs Smith had a left-sided paresis and was unable to speak or swallow. and medications were given via the PEG tube. When he was unable to continue with full-time care. water. She was able to understand simple directions and seemed to know her relatives. Mrs Smith had been admitted to an aged-care facility. Her main carer was her husband. Formula. Mrs Smith therefore took nothing by mouth.

and dried. over several months. Mrs Smith’s bolus enteral nutrition was given using a catheter-tipped syringe. This ensured that she was given 2000 millilitres of fluid daily. . Because there was a risk of reflux and aspiration. with 100-millilitre water flushes. (In general. The formula and equipment were ordered from a wholesaler and was subsidised by the Australian government. It was not possible to weigh Mrs Smith on admission to the facility. Problem Requires assessment and recommendations regarding PEG feeding (with special attention to problem of diarrhoea). Mrs Smith had a very ‘fruity’ cough.) The PEG site was red and irritated—due to constant serous ooze mixed with formula and bile. Nevertheless. residents who have low-residue formulae have bowel motions twice weekly. However. Mrs Smith was not ambulant and sat in a chair most of the day.286 Nursing Documentation (continued) Mrs Smith had been seen by a dietitian before leaving hospital. the nutrition was given slowly. She had diarrhoea—which consisted of 2–3 liquid bowel motions daily.The dietitian had ordered 300-millilitre bolus enteral nutrition of a low-residue formula (of 1 Calorie per millilitre) five times each day. The site was bathed daily using warm soapy water. and Betadine was used periodically. A cortisone cream had been ordered for the red skin. it was apparent that her weight had increased dramatically.

The following suggestions were therefore documented on the nursing-care plan as a strategy for the management of enteral nutrition: . • The tube appears to be working well and probably has another 6 months of life. • decrease the amount of formula to 200 millilitres (x 5 daily). • The tube could be shortened to a more manageable length— approximately 20–30 cm—and a new Y-port connector should be attached. 2. Gastrostomy tube The following were documented in the progress notes to ensure that staff members knew the status of the tube. • The tube can be removed at the bedside and replaced with a balloon gastrostomy tube of the same French size (20). Delivery Bolus feeding is not indicated for clients with a history of reflux and/or aspiration. To decrease and monitor Mrs Smith’s diarrhoea: • change from a low-residue formula to a fibre formula—to assist in providing bulk to the stool.287 Appendix 7 PEG Nutrition Documentation for this case study The clinical nurse specialist’s documented recommendations for this case were as follows. 3. Formula The following information was documented in the progress notes and in the nursing-care plan to ensure that all nurses were aware of the requirements. 1. followed by a flush of 100 millitres (x 5 daily)—which will still meet Mrs Smith’s recommended dietary intake (RDI). and • maintain a fluid balance chart to ensure that all fluid amounts are correctly recorded.

The amount of leakage around the stoma site will decrease with a lower volume of formula. • Apply sorbolene and zinc cream to the skin for better protection from the ooze. or use an enteral pump. . 4. • Advise referral of Mrs Smith to a speech therapist for assessment of her swallowing capacity. • The clinical nurse specialist to review Mrs Smith in 6 months and change the PEG tube to a balloon gastrostomy tube. 5. A wound-management chart (with a cross-reference made in the nursing-care plan) therefore documented the following recommendations.288 Nursing Documentation • • change to ‘gravity feed’ using a flexitainer and gravity-feeding set. Stomal site Serous ooze and granulation tissue around the site is normal. • A gauze dressing should be applied only if soiling the clothing. • Advise referral of Mrs Smith to a dietitian to assess nutritional status. Other recommendations The following recommendations were recorded in the progress notes and in the nursing-care plan.

widowed. Mrs Elle almost never spoke.Appendix 8 Wandering Beverly Smith Case study Mrs Elle Presenting problem and history Mrs Elle was an 80-year-old woman who had lived in an aged-care facility for several years. Although she appeared to have some comprehension. Mrs Elle had been diagnosed with dementia several years previously when she was living alone. Her absconding had occurred at unlikely times and in an unlikely manner. Mrs Elle had lived with her daughter and granddaughters for five years. on the family farm. and was able to climb through windows and manipulate fastenings. She was unusually agile and strong for her age. Her confusion and disorientation had increased significantly in the past 18 months. Once outside. Before admission to the facility. (continued) . she would sit in the garden or disappear—forgetting where she had come from. Admission to the aged-care facility had been precipitated by Mrs Elle’s absconding from home on a number of occasions.

and then to her bed. Her daughter had endeavoured to maintain a routine similar to Mrs Elle’s earlier lifestyle—with early-morning rising. A graphical flowchart indicated that Mrs Elle usually wandered with some purpose. and eventually stopped as her general health deteriorated. Family involvement Mrs Elle’s family members timed their visits to enable them to be with her to sit. then slowed. She often became quite opportunistic and belligerent—such as when she was around the secured front door at busy times. and encouragement to eat and drink. Her daughter was able to introduce relaxation massage gradually. talk. . and gardening and walking on most days. Admission assessment Mrs Elle’s admission assessment highlighted wandering and restlessness— with potential for danger by falling or absconding. prior to her death. She was eventually confined to her chair.290 Nursing Documentation (continued) Mrs Elle needed assistance with all aspects of daily living. She was sometimes intrusive and asocial. Management and documentation The nursing-care plan and documentation is discussed below (see page 291). Problem The differential nursing diagnosis was between wandering as a problem and ‘ordinary walking’. Her balance and stamina became impaired. On occasions she was not amenable to reason. Progress Mrs Elle’s wanderings continued for some weeks after surgery for a fall. Mrs Elle was much loved and respected by her family. reminders for toileting and meals. and listen to music. Nursing care needed to be planned accordingly. prompt completion of household tasks.

Date 31 Dec. • minimisation of distractions and interruptions that could deflect her concentration. • attention to environmental needs—including clear pathways on her walking routes with appropriately closed doors. These included: • neat clothing and grooming. Restraint was not considered to be an option. 2005 Problems and needs Wandering Potential for absconding Closed-in Refusal to cease walking most of the day Unable to stop Disorientation Maintain safety Maintain mobility Maintain quality of life and ‘freedom’ Reduce potential for falls Adhere to security measures Monitor whereabouts Use calm approach and maintain a calm environment Monitor carefully for fatigue Encourage use of hand-rail Reduce distractions and obstacles Use sensor mat at night to indicate need for intervention Goals Interventions and strategies (continued) . • properly applied footwear. by short garden walks. Quality of life was the predominant concern—and for Mrs Elle that meant ‘freedom’. Strategies were implemented to promote dignity and safe mobility. Mrs Elle’s full nursing-care plan is shown below. • ensuring that she was occupied or gently redirected at assessed ‘problem times’—for example.291 Appendix 8 Wandering Documentation for this case study Nursing-care plan A family conference was held at which Mrs Elle’s care was discussed.

dressing. 2005 Problems and needs Intrusive behaviour With others’ belongings Entering rooms Confusion Anxiety Looking for someone Maintain dignity. meals. and grooming Maintain privacy of others Staff be aware of Mrs Elle’s whereabouts Staff distinguish ‘problems’ from safe. 2005 Restlessness ‘Prowling’ Potential danger of injury from falls Potential escalation to other behaviours . snacks Orientate and trial cues such as family photos Check for comfort such as resettle with toileting or hot drink Encourage Mrs Elle to sit and ‘chat’ with volunteer or family Goals Interventions and strategies 31 Dec. casual walking Maintain safety. minimise agitation Ensure staff understand her routine and adhere to it Minimise problem wandering by monitoring whereabouts Attending to daily needs such as toileting.292 Nursing Documentation (continued) Date 31 Dec.

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202. 101. 125. 191 stomal care 275 systems model 222. 190 activities of daily living 12. 222. 47. 290. 222 access to documentation accuracy of documentation behaviour and emotion 97. 231. 59 progress notes 71. 15. 190. 140 staff issues 187 systems model 216. 74. 73. 180 incident reports 151. 108 clinical pathways 94 design of documentation 207 evaluation 176. 16 accreditation 25. 256. 68. 102. 244 understanding documentation 6 clinical reasoning and 24. 228. 76 staff issues 188 systems model of documentation 216. 217. 59 nursing-care plans 58. 134 professional communication 33 progress notes and 64. 65. 148. 5. 141. 130. 71. 174–5 adult learning 121. 185. 220 understanding documentation 13. 177. 107. 8 accountability of documentation clinical pathways 90 clinical reasoning 23 incident reports 155 nursing-care paths 58. 74. 67 restraint 139. 238. 105. 61 pain management 123. 127. 77 restraint 149 staff issues 182. 130. 188. 98. 28 complementary therapies 111. 112 nursing-care plans and 47. 292 activities programs 259 actual behaviour. 74. 122. 236 .Index abbreviations 6. 75. 166 nausea 271 nursing-care plans and 57. 133. 67. 136. 198. 59 professional communication and 43 progress notes and 63. 223. recording of 101–3. 232 understanding documentation 3. 115. 65. 73.

269. 139. 242 ulcer 280. 267. 57. 100 anti-discrimination policies 121. 269 visual 12 wandering 290. 87 progress notes 63. 15. 251–2. 292 appeals policies 121. 16–17 attrition of staff 182. 46. 113. 250. 227–8. 142 speech therapy 288 stoma 274 systems model and 212. 123. 279. 114. 177. 64. 177. 256. 88. 142 elimination 12. 69. 90 clinical reasoning 29. 43 reliability 33. 131. 269 PEG feeding 286 physiotherapy 12. 135. 249. 177. 131. 40. 281. 101. 256. 186–8. 100. 112. 185. 120. 290. 183. 271. 256. 72. 218. 177 incident reports 156 manual handling 12 mini-mental 114. 114. 190 archives 75 aromatherapy 117–18 arthritis 51–2. 184. 135. 201. 155. 291 wounds 114. 214. 86–7. 187 anxiety 25. 47. 258. 60 nutrition 12. 127. 90 clinical reasoning and 27 nursing-care plans and 56 pain management 134 professional communication 35. 100. 191 auditing design of documentation 199 . 292 balance 87 behaviour and emotion 12.300 Index advertisements 183. 115. 53. 210. 142. 235 understanding documentation 4. 156 affect 99 aged-care nursing. 234. 114. 271 nursing-care plans and 31. 113–14. 145 safety risk 12 sensory 12. 148. 98. 142 complementary therapies 110. 36. 88. 270. 145. 142. 125. 255 hearing 12. 139. 236–8. 114 credentialling and 190 depression 12. 52. 288 pain 12. 114. 142. 133. 140–1. 212. 56. 282–3 understanding documentation 12 urinary 178. 259 clinical assessment 12 clinical pathways 85. 48. 139. 114. 258 systems model and 209. 112. 141–2. 177 clinical pathways 89. 269. 177 sexual health 12 skin 12. 37–9. 140–1. 258 special senses 114. 56. 181. 114. 42. 213. 70. 265 social 110. 114. 270. 257. 130. 185 advocacy 33. 250. 180 falls 87. 283 assessments (nursing process) activities of daily living 12. 99. 269 environmental 256 evaluation and 179. 41. 256. 132. 46. 142 geriatric assessment 54. 124–30. 30 communication 114. 99. 142 attitudes of staff mobility 12. 87. 142 nausea 268. 114. 77 restraint 138. 257. 128 hydration 114. 256 sleep patterns 12. perceptions of clinical pathways and 85 different views of nursing 50–1 nursing-care plans and 55–6 assessments (continued) Alzheimer’s disease 46 anger 98.

24. 10. 228. 114. 214. 259 benchmarking 9. 103 ‘sundowner syndrome’ 103 systems model 241 timeliness 107 wandering 292 balance assessment 87 behaviour and emotion 97–108. 13 blank spaces and lines 6. 108 progress notes 77 quality care and 97 recognising clues 98–9 recording actual behaviour 101–3 recording change 103 reliability 98 behavioural-modification programs 170. 262–5. 283 blood pressure 119. 177. 102. 101. 238. 258. 273. 83. 100 evaluation and 170. 86–7. 105 depression 98. 132. 101. 105. 87. 60 pain management 134 progress notes 60. 100. 10–11. 103. 256. 255–9 accuracy 97. 101. 259 nurses’ emotional responses 100 objectivity 100 pain management 98. 29. 224. 100 anxiety 100 asking questions 99–100 assessments (nursing process) 12. 67. 283 cardiac failure 53. 106. 147 systems model and 212. 175. 259 astute nursing 98. describing 101 behaviour. 105 individualising care 101 nursing-care plans and 48. 99. 72 clinical governance 211–15. 130 professionalism 98. perceptions of 85 assessments (nursing process) 85. 239. 215 charting-by-exception 66. 101. 257. 240. 108 affect 99 anger 98. 170. 52. 11 behaviour and emotion (continued) restraint 142. 103. documenting 101–3 behavioural management case study 255–9 cognitive state 98. 104. 258. 187. 99. 100. 241–2 understanding documentation 10. 43 progress notes 64 restraint 145. 178. 214. 103. 108 complementary therapies 114 delirium 97. 171. 177 food intake 103–4. 145 sleep patterns 103–4 social history 98. 142. 13. 65. 104. 158–9. 213. 212. 235. 90. 147. 237. 107. 88. 174. 239–40. 153. 107 dementia 98. 120. 176. 105. 216. 104. 273 care pathways see clinical pathways care plans see nursing-care plans change agents 9. 92 clinical reasoning 19. 108 emotion 98–100 empathy 98. 66 systems model 211. 235. 244 understanding documentation 5. 100. 30 nursing-care paths 58 nursing-care plans 58. 283 building maintenance and safety 147. 39. 98. 60. 250. 90 . 107. 106–7 basic functions 103–5 behaviour. 70–1. 240 best practice clinical pathways 80. 145. 68. 125. 166 cancer 46.301 Index auditing (continued) nursing-care plans 47 professional communication 32. 136 blood glucose 177. 98. 233 clinical pathways 79–95 access 90 accuracy 94 advocacy 88 aged-care nursing. 177. 84.

94 referrals 83. 95 multidisciplinary teams 80. 85. 22. 85. 82. 25. 30 group experience and 23 implementation 21. 83. 30 attitudes of staff 27 best practice 19. 27–8 professionalism 19. 25 legal requirements 28 management and organisational issues 22. 85. 90. 81. 90. 29. 85. 80. 58–9. 30 evidence-based practice 26. 82. 85. 30 communication and 23. 89 implementation 58. 22. 88. 95 individualising care 83. 24. 84. 92 effective documentation and nursing 79. 91. 86. 84. 88–9. 92. 24–7 nursing teams 23. 29 innovation in documentation 29. 87 values and value judgments 81 variance and variance analysis 80. 29. 81. 83. 92 falls 87 funding 89 guidelines 82–3 health outcomes 82–3 holistic care 86. 82. 84. 90. 26. 81. 86. 93 nursing-care plans and 45. 28–9. 26. 30 individualising care 22. 28. 30 evaluation 28. 87. 86 evaluation 82. 30 information-processing theory 20–1 initiative and innovation 28. 28. 30 regulatory requirements 19. 83. 28 assessments (nursing process) 29. 85 evidence-based pathways 79. 27. 25. 80. 27. 89 continuity of care 89 definitions of terms 80–3 dementia 88. 94 resident pathway 81 social issues 86 staff satisfaction 85. 25. 90 objectives and results 83–4 professionalism 79. 86. 29. 25 conflicts with documentation requirements 24–8 decision theory 20. 86. 90 best practice 80. 30 interventions 20. 87. 89–90 clinical pathways (continued) clinical reasoning 19–30 timeliness 84 validity 81. 23. 29. 27 political factors 19. 87. 90 management and organisational issues 79. 82. 24. 27. 81 evidence-based practice 79. 84. 85. 91–4. 89 depression 87 design and implementation 91–4 education 81. 24. 88. 29. 24. 94 access 23 accountability 24. 88 interventions 79. 21 definition of 19 dementia and 20 differing expectations 27–8 education 30 effective documentation and nursing 22. 83. 86. 94. 82. 83. 90. 83. 22. 28. 92. 23. 90. 86. 86–7 reliability 87 research 92 resident-centred care 80. 83. 26.302 Index clinical pathways (continued) attitudes of nurses 89. 30 . 21. 90 streamlined documentation 85. 84. 23. 85. 92 cognitive impairment 88. 83. 85. 25. 93. 28 experience and 19. 93. 24. 26. 86. 84. 20. 29 quality control and improvement 26. 85. 81. 28. 29 nursing-care plans and 21. 86. 81. 91. 29 funding and 24. 94 qualifications of staff 89 quality outcomes and improvement 79. 90.

29 validity 21. 259 clinical pathways 88. 100. 121 evidence-based practice 110 grievances 121 holistic care 110. 111. 111. 120. 113. 117 dates and time 115. 134 restraint 143. 119 qualifications of staff 111. 119–20. 21. 75. 110. 117–19 cognitive state 116. 22–4. 119. 110. 116 programs 110. 122 hydration assessment 114 implementation 109. professionalism skills-acquisition theory 19. procedures. 117. 138 codes of ethics 32–3.303 Index clinical reasoning (continued) coaching 37–8 Cochrane Collaboration 217. 121 ethical issues 110. 115–16. 21–2 social issues 19. 111. 110 policies. 14. 59 commercially designed forms 182. 119 communication 114 confidentiality 120 consents and authorities 110. 189. 182. 103. 113. 32. 113. 117. 120 evaluation 109. 106. 113. 122 referrals 114 regimens 111. 115. 113 professionalism 111. and protocols 110– 112. 121 quality improvement 115. 112. 67. 117. 119 constipation 251 design of documentation 201 nursing-care plans 48 pain management 129. 26. 114. 33–4. 24 ‘sundowner syndrome’ 20 theoretical plans and clinical experience 24–7 three theories of 19–22 understanding of those in care 20. 240 complementary therapies 109–22 accountability 111. 118 research 120 . 130. 218 codes of practice see also ethics. 133. 193 communication see professional communication complaints 17. 114. 110. 114 behavioural patterns 114 behaviour and emotion 98. 121 individualising care 115 legal issues 110–11. 116. 27 complementary therapies (continued) cognitive state codes of conduct 2. 121 medication 113 mini-mental examination 114 mission statement 111 mobility 114 multidisciplinary teams 111 nutritional assessment 114 occupational health and safety 111. 89 complementary therapies 116. 114. 114–115. 115–17 management and organisational issues 109. 223 codes of professional practice 2. 108. 120. 112 accreditation 122 anti-discrimination 121 appeals 121 aromatherapy 117–18 assessments (nursing process) 110. 119. 117. 155. 112. 112. 216. 118 definition of 109 depression 114 education 110. 112. 43. 23. 113. 113. 43. 9. 99. 147 systems model 235 understanding documentation 12 benchmarking 120 care plans 110. 112 pain assessment 114 planning 109. 121 effective documentation and nursing 115.

66. 123. 145 validity of 115. 250. 240 understanding documentation 5. 103. 120. 217. 98. 105. 174 dementia behaviour and emotion 98. 174. 101. 229. 276 continence programs 256 continuity of care clinical pathways 89 evaluation and 170. 238 restraint 143. 231 evaluation of 10. 218. 173. 114. 227. 177. 104. 206. 59. 230. 70 pain assessment 124 recording of 48 sociodemographic 112 subjective 69. 269. 240 confidentiality of 120. 234–5 ‘DAR’ charting method 70 data confidentiality and privacy consent constipation 52. 165 progress notes 74. 207 incident reports 157 progress notes 65. 116–117. 172. 158 nursing-care plans 47. 115–16. 112 signatures and designations 110. 156. 231 electronic 182. 122 resources 111. 255 . 147 databases 217. 115. 142–4. 271. 240 graphical 200.304 Index complementary therapies (continued) resident-centred care 111. 113. 120 special senses 114 spiritual issues 113 validity 120 vision statement 111 wound assessment 114. 11. 238. 183. 73 understanding documentation 3 complementary therapies 110. 119 complementary therapies 120 incident reports 155. 208. 112–14. 145 systems model 222. 171. 219. 147. 253. 107. 114. 188. 249. 118 design of documentation 203–4. 75–6 restraint 147 systems model 222–3 understanding documentation 5. 225. 46. 175 critical thinking 14. 222 counselling 187. 142. 175. 201 validity of 120. 171. 115. 201 interpretation of 71 objective 69 occupational health and safety 166 omission of 68 organisation of 11. 67. 120 skin assessment 114 sleep patterns 114 social issues 110. 166. 60 progress notes 64. 154. 219. 179–80 incident reports 153. 66. 251. 271 credentialling of staff 182. 190–1 decision theory 20. 57. 117 disciplinary issues 189 progress notes 74 restraint 138. 232. 68. 116. 143. 144 dates and time analysis of 11 assessment of 64 bias in 147 clinical 77 collection of 10. 135. 65. 270. 8 wandering 292 Crofton–Witney model for documentation 209–44 criterion-referenced evaluation 170–1. 6 copyright 207 corrections to documentation 6. 230. 229. 21 delirium 97. 218. 176 variance in 82 complementary therapies 115. 116.

273. 206. 255–9 clinical pathways 79–95 clinical reasoning 19–30 complementary therapies 109–22 definition of 2 design of 193–208 diabetes 261–5 evaluative criteria 169–80 faecal incontinence 249–53 importance of 3 incident reports 151–67 key terms 2 leg ulcer management 279–83 nausea 267–72 nursing-care plans 45–61 pain management 123–36 PEG nutrition 285–8 praxis 13–14 principles of 65 professional communication 31–43 progress notes 63–77 purposes of 3. 261–5. 142 behaviour and emotion 98. 198 trials 207 typefaces 197. 63–4 restraint 137–49 staff issues 181–91 stomal care 273–7 streamlined documentation 85. 197. 283 discipline of staff 181. 54 pain management 123. 108. 198. 198. 10. 198. 201 wandering 285 design of documentation 193–208 assessment 12. 74. 207 logic 197. 207 graphical and pictorial representations 200–2 identification of form 197. 222 education and documentation clinical pathways 81. 68. 141. 189– 90. 89–90 systems model of 209–44 understanding documentation 1–17 wandering 289–92 . 59 pain management 123. 54. 103. 206–7 multiple alternatives 204–5 names 206 paper grade and size 194–6 presentation 197. 207 language 206 layout 197. 198. 131. 193 computer software 197 copyright 207 dates 203–4. 191 diversional therapist programs 257 documentation see also individual index entries duty of care 3. 198–9 review dates 207 signatures 206–7 title 197. 202. 114. 205 legal aspects 193. 182. 152. 199–205 principles of design 197–207 professional nursing and 208 purpose of forms 193–4. 86.305 Index dementia (continued) depression clinical pathways 88. 154. 258. 89 clinical reasoning and 20 nursing-care plans 53. 5. 92 clinical reasoning 30 behaviour and emotion 97–108. 14. 199–200 yes/no answers 204 designation see signatures and designations destruction of records 6 diabetes 198. 133 restraint 142 abbreviations 202 accuracy 207 capitalisation 202–3 commercially designed forms 182. 259 clinical pathways 87 complementary therapies 114 evaluation 174 nursing-care plans 46. 183. 104.

237. 179–80 credentialling 190 criterion-referenced evaluation 170–1. 11. 178 clinical indicators 170. 171. 8. 172. 120 nursing-care plans and 60 professional communication 32–3. 92. 190–1 diabetes 265 incident reports 156 nursing-care plans 57 pain management 133–4. 121 credentialling of staff 182. 135 professional communication 30. 186. 172 formative evaluation techniques 170. 190. 147–8 staff issues 187. 69 restraint 138. 81. 171. 64. 251–2. 121 continuous process 170. 176. 35. 177. 215. 175 delirium 174 depression 174 elimination 177. 121 design see design of documentation incident reports 151. 160. 177. 16 errors see corrections to documentation ethics evaluation and evaluative criteria 169–80 codes of ethics 32–3. 175. 188 individualising care 172 language and value judgments 174–5 mobilisation 170. 182. 166 nursing-care paths 58 nursing-care plans 47. 135. 132–4. 100. 180 actual behaviour. 183. 42. 76 restraint 147. 120. 83. 28–9. 140–1. 133. 32. 121. 30 complementary therapies 115. 113. 117. 136 professional communication 31. 178. 250. 217 elimination patterns 12. 180 behaviour 170. 178. 36. 240 understanding documentation 2. 180. 147 systems model 219. 43 progress notes 67. 74–5 restraint 138. 174. 188 environmental assessment 256 clinical pathways 79. 232. 234–6 effective documentation and nursing complementary therapies 110. 58. 220. 98. 189. 180 emotions 174 evidence-based practice 169 falls 170. 269 emotion see behaviour and emotion empathy 50. 51. 3. 61 pain management 129. 187. 148 systems model 214 accepted rules 170 accuracy of documentation 176. 40. 223. 171.306 Index education and documentation (continued) educational programs 11. 65. 234–6. 110. 64. 119. 188 employment contract 185. 86 clinical reasoning 22. 23. 113. 139. recording of 101–3. 239. 174–5 assessments (nursing process) 179. 14. 57. 177–9 clinical pathways 82. 48. 43 progress notes 63. 6–7. 190 systems model 212. 158. 178 multidisciplinary team 180 norm-referenced evaluation 170–2 nursing-care paths 58 . 177. 171. 85 clinical reasoning 28. 177. 259 employee-assistance programs 186. 259 blood glucose 177 blood pressure 170. 17 electronic documentation 76. 43 complementary therapies 110. 8. 40 progress notes 64. 119–20. 31. 227 understanding documentation 2. 30 complementary therapies 109. 148.

207. 176. 174. 175. 17 clinical pathways 79. 178 exercise programs 252 experience of nurses leg ulcers 281 nursing-care plans 60 pain management 134 professional communication 39 systems model 211. 233. 114. 57. 132 functional needs 48. 70 food intake and nutrition 12. 265. 145. 28. 171. 86. 214. 178 quality 180 reliability 170. 251–3. 176. 173. 180. 147. 232. 234. 229. 255 . 185. 172. 58. 172. 35 progress notes 63. 242. 146. 25. 171. 142. 73 systems model 211. 173. 23. 24. 148 sensory assessments 177 stomal care 275 subjective measurements 170. 85. 104. 292 feedback 21. 187. 92 clinical reasoning 26. 237. 180 systems model 214. 264. 242 temperature 177 understanding documentation 10. 48. 60 professional communication 31. 276. 214. 83. 173. 212. 28 complementary therapies 110 evaluative criteria 169 incident reports 161 gap analysis 39–41 geriatric assessment 54. 114. 64. 178. 177. 29. 4. 264. 27. 215–19. 170. 102. 177. 291. 218. 173. 42. 175 organisational issues 172 pain assessments 177 performance appraisals 188 professional communication 40. 259 nutrition and hydration 177. 145. 23. 233. 103. 139. 90. 237. 217. 155. 262. 171. 171. 30 nursing-care plans 45. 175. 56. 235 understanding documentation 5. 170. 152. 22. 104. 10 see also qualifications of staff clinical reasoning and 19. 11 urinalysis 177 urinary tract infections 170 validity 170. 158. 48. 16 faces-rating (pain) scale 129–30. 175 progress notes 69 psychometric evaluations 177 pulse rate 177. 290. 3. 188 fractures and sprains 131. 81. 32. 178. 180. 239 file management 75–6 fluid and hydration 12. 239. 180 objective measurements 169. 21. 177 research 172 respiratory rate 177 restraint 138. 48. 170. 26. 41. 171. 287 focus charting 68. 29 understanding documentation 15. 51 funding clinical pathways 89 clinical reasoning and 24.307 Index evaluation and evaluative criteria (continued) evidence-based practice (continued) evaluative criteria see evaluation and evaluative criteria evidence-based practice nursing-care plans 46. 285–8 formative evaluation techniques 170. 213. 20. 38–9. 155. 172. 173–5 summative evaluation techniques 170. 201 faecal incontinence 249–53 falls 52. 171. 178. 244 understanding documentation 1. 131. 130. 87. 174–5 variances 176 weight 176 wound and skin assessments 177. 177 values and value judgments 169.

219. 180. 159. 156. 167 regulatory compliance 156 . 17 incentive programs 187 incident reports 151–67 human-resource management 181. 262–5. 95 clinical reasoning 21. 200–1. 164 hospitality services 156 importance of 153–4 individualising care 155 infection control 156 inventory management 151. 158. 58 professional communication 35. 43 restraint 139. 157. 153. 36. 162. 159. 167 maintenance 151 management and organisational issues 151. 166. 179. 237 understanding documentation 3. 48. 157. 26. 166 advocacy 156 aged-care facilities 156 buildings 147. 164. 276. 167 medication 155 mission statement 152 near misses 159–60 nurses 156 occupational health & safety 151. 166 investigating incidents 161–6 leadership 156 legal issues 152. 156. 161. 218. 159. 157. 12. 178. 191 hydration and fluid 12. 283 government regulation see regulatory requirements graphs 175. 230 hazards 145. 34–5 progress notes 71 restraint 138 systems model 210. 158 critical thinking 154. 251–3. 213. 216. 114. 158–59.308 Index glucose (blood) 177. 145. 166 clinical issues 158 confidentiality and privacy 155. 41. 177. 155. 121 evaluative criteria 170. 158. 128 holistic nursing practice clinical pathways 86. 159. 42. 104. 190 handbooks 115. 22. 264. 169 healthcare teams see multidisciplinary teams hearing assessment 12. 84. 153. 111. 86. 57. 165 continuity of care 153. 110. 258 clinical pathways 82. 83. 166 dates and time 157 deciding what to report 154–7 definition 152 duty of care 154 education 156 effective documentation and nursing 151. 112. 122 professional communication 33. 287 immobility see mobility implementation behavioural management 170. 30 complementary therapies 109. 224. 160. 140–1. 202. 228. 160. 180 nursing-care paths 58 nursing-care plans 45. 159–66 policy 152 professionalism and 153. 186. 184. 153. 154. 92. 94. 48. 153. 141 staff issues 188 systems model 211. 160. 85. 91. 39. 93. 156. 153. 119. 153. 170. 220. 158. 111. 154. 166 falls 152 hazards 145. 236. 158. 158. 290 grievance rights 121. 156. 163. 139. 236 understanding documentation 9. 161. 160. 157 progress notes 74–5 quality control and improvement 164 recording reports 151. 89 complementary therapies 110. 218. 14 wandering 291 access 155 accuracy 151.

82. 207 duty of care 3. 52. 174–5. 88. 17 maintenance of equipment 139. 66. 80. 53. 166 management and organisational issues clinical pathways 79. 190. 81. 40. 130. 153. 10. 49. 142. 55. 232. 57 professional communication 34. 140–1. 241 legibility 5. 206 layout of documentation 197. 70. 222 language and jargon 15. 59. 67. 74–5. 142–4. 80. 158. 223 understanding documentation 3. 165. 46. 30 complementary therapies 115 evaluative criteria 172 incident reports 155 nursing-care plans 45. 90. 71 restraint 143. 67. 156. 115–16. 151. 205 leadership incident reports 156 nursing-care plans 56. 202. 222 clinical reasoning 28 complementary therapies 110–11. 87. 233 interventions behavioural management 257. 99. 178. 220. 167 nursing-care plans 48. 11. 72 understanding documentation 9 leg ulcers 279–83 legal issues integrated progress notes 68. 58. 88 clinical reasoning 22. 113. 158–9. 222. 65. 159. 90 clinical reasoning 20. 14. 251. 271 nursing-care plans 48. 74. 154. 17 pain management 135. 23. 74. 68. 76 restraint 138. 274 individualising care see also resident-centred care reporting arrangements 157 research 161 residents 154–6 responsibility 157–9 restraint 145 risk see risk management safety triangle 160 sleep patterns 155 social issues 156 standard of care 152 understanding documentation 6. 113. 60 professional communication 38 progress notes 71. 117. 42 systems model 216 understanding documentation 9 behaviour and emotion 101 clinical pathways 83. 84. 43 systems model 216. 258. 224 understanding documentation 2. 64. 52. 222 incident reports 152. 24. 86. 138. 73 Internet 183. 152. 249. 91–4. 10. 259 clinical pathways 79. 136 progress notes 67. 145 design of documentation 193. 50. 65. 47. 115–17 consent 74. 189. 4–5. 68. 135. 59 professional communication and 32 progress notes 63. 191 systems model of documentation 222. 110. 253. 71. 5. 198. 143. 250. 29. 185. 147 systems model 241 wandering 291–2 information-processing theory 20–1 initiative and innovation clinical reasoning 28. 83. 151. 141. 29 professional communication 34. 166 jargon 15.309 Index incident reports (continued) incontinence 46. 149 staff issues 184. 48. 114. 95 . 22. 41. 164. 57. 231. 5–6. 136. 144. 65. 70. 8 vision statement 152 interventions (continued) inventories 125. 144. 25 leg ulcers 281 nausea 270. 87.

87. 34. 3. 16 narrative progress notes 68. 252 incident reports 155 aged-care nursing see aged-care nursing. 143. 282 nurses and nursing see also individual entries mini-mental examination 114. 134 . 220 mobility assessments (nursing process) 12. 90. 72 restraint 138 systems model 219. 117. 25. 264. 29 complementary therapies 109. 251. 69. 42. 157. 35–8. 189–90. 111. 74. 8. 163. 86. 253 incident reports 155 leg ulcer management 283 nausea 268. 121 costings 47–8 evaluation 172 incident reports 151. 158. 8. 70. 110. 110. 13. 125–30. 167 nursing-care plans 45. 39–41. 7. 9. 5. 92. 156. 51. 160. 183. 88. 4. 145 clinical reasoning 22. 166. 64. 146 understanding documentation 12 wandering 291 clinical pathways 80. 15. 7. 84. 131 restraint 142. 244 understanding documentation 2. 142 mission statements 111. 251. 140. 71–3 nausea 267–72 NCPs see nursing-care plans norm-referenced evaluation 170–2 North American Nursing Diagnosis Association (NANDA) 47 numeric rating scales 119. 70. 53 pain management 127 PEG nutrition 285 progress notes 71 restraint 137. 270. 269. 178. 182. 219–21. 180 faecal incontinence 249. perceptions of astute nursing 52–3. 139. 112. 142. 138. 135 different views of nursing 50–1 discipline of staff 181. 106–7. 136 professional communication 31. 216. 144. 221. 33. 93 complementary therapies 111 evaluation and evaluative criteria 180 nursing-care paths 58 nursing-care plans 54. 34. 14–17 multidisciplinary teams see also nursing–teams leg ulcers 280 nursing-care plans 46. 58. 114. 154. 139. 201–2. 152. 11. 57. 50. 83. 52. 47–8. 141. 85. 91. 265 faecal incontinence 250. 191 emotional responses of 100 erroneous beliefs re pain 133. 43 progress notes 63. 98. 11. 132 attitudes of see attitudes of staff documentation see documentation designation 5. 162. 120. 33. 114. 142 behavioural management 256 complementary therapies 114 evaluation 170. 60 professional communication 32. 159. 250. 226–8 understanding documentation 1–2. 271 nursing-care plans 48. 147 risk management see risk management systems model 209–10. 81. 6. 28. 55. 56. 263. 65. 71. 211. 145. 10. 53 pain management 125. 40 progress notes 68. 100. 49. 75–6 restraint 138. 153. 66. 60 pain management 135.310 Index management and organisational issues (continued) mobility (continued) manual-handling assessment 12 medication behavioural management 256 complementary therapies 113 diabetes 262. 237.

52. 47. 188. 55. 57. 53 assessments (nursing process) 31. 57. 57. 58 incontinence 46 individualising care 45. 53 multidisciplinary teams 54. 58–9. 57. 60 interventions 48. 57. 187. 58. 60 empathy 50 ethical responsibility 60 evaluation 46. 52. 40 performance appraisal 181. 47–8. 48. 59 accreditation 47 accuracy 57. 27. 59. 58–9 cancer 46 cardiac failure 53 clinical audits 47 clinical pathways and 45. 48. 48. 259 evidence-based practice 60 falls 52 fluid balance 48 food intake 48 functional independence 48 funding 45. 59 different views on nursing 50–1 education 57 effective documentation and nursing 47. 57 legal issues 48. 59 management and organisational issues 45. 50. 113.311 Index nurses and nursing (continued) nursing-care plans (NCPs) 45–61 holistic care see holistic nursing practice interventions see interventions nursing-care plans see nursing-care plans (NCPs) nursing diagnosis 46 nursing notes 48 nursing problems 46 nursing process 46 nursing teams 23. 52. 60 benefits of NCPs 47–8 best practice 58 care pathways 45. 59. 61 elimination patterns 48 emotional state 48. 46. 60 nursing diagnosis 46 nursing notes 48 nursing problems 46 nursing process 46 observations 46 objectivity 48 Parkinson’s disease 46 problem-intervention statements 48 problems with NCPs 48–50 professionalism 45. 60 medication 48. 49. 54. 61 aged-care nursing undervalued 55–6 anxiety 46 Alzheimer’s disease 46 arthritis 51–2. 191 progress notes see progress notes qualifications see qualifications of staff registration bodies 111. 56. 47–8. 51. 26. 58. 58. 48. 60 implementation 45. 50. 85. 50. 54. 71 leadership 56. 49. 52. 57 nursing-care plans (NCPs) (continued) complementary therapies 110. 242. 58. 60 attitudes of staff 56 auditing 47 behaviour and emotion 48. 55. 59 accountability 47. documentation of verbal tradition of 47. 117–19 constipation 52 continuity of care 47. 60 critical analysis 46 dementia 53 depression 46. 46. 25. 182. 90 clinical reasoning and 21. 114. 24–7 codes of practice 59 cognitive state 48 communication 48. 222 visibility of work 47. 34. 141 staff issues see staff issues. 51. 58. 59. 183. 56. 138. 56. 47. 55. 67. 59 access 58. 60 . 57. 51. 53. 49.

documentation of 181 systems model 223 . 218. 171. 53 values and value judgments 49. 153. 177. 114.312 Index nursing-care plans (NCPs) (continued) nutrition and food 12. 178. 174. 15 urinary tract infection 52. 49 visibility of nurses’ work 47. 57. 178 evidence-based practice 134 faces-rating scale 129–30 faecal incontinence 249. 256. 130. 112 incident reports 151. 54. 60 staff/resident ratios 50. 177. 52. 104. 77 qualifications of staff 49. 71. 131 multidisciplinary teams 135. 130. 57 systematic assessment 46. 146 ‘SOAPIE’ system 48 social issues 46. 256. 132. 238 temperature 48 understanding documentation 9. 130. 53. 175 nausea 268 nursing-care plans 48 pain management 201 progress notes 69 restraint 147. 170. 133. 135. 140. 156. 134 evaluation and evaluative criteria 177. 132 incidence of pain 123–4 interventions 135. 58 verbal tradition of nurses 47. 50. 104. 124–30. 202 diagram of body 202 education about pain 133–4. 72. 60 referrals 58 resident-centred care 50. 159–66 programs 164 restraint 139. 270 observations 46 occupational health and safety organisational issues see management and organisational issues complementary therapies 111. 130 erroneous beliefs of nurses 133. 53. 135. 269 attitudes of nurses 134 barriers to communication and documentation 132–4 behaviour and emotion 98. 56. 48. 135 effective documentation and nursing 129. 222. 61 quality improvement 47. 58. 250 fractures and sprains 131. 132–4. 60. 264. 136 emotional state 125. 51–7. 136 myths 132. 59 osteoarthritis 131. 148 stomal care 275 systems model for documentation 217. 214. 131. 48 systems model and 212. 134 complementary therapies 114 corrections 135 definition of pain 123 delirium 123 dementia 123. 233 understanding documentation 5 progress notes and 67. 59 restraint 138. 141 staff issues. 180. 255. 201. 279 pain management 123–36 accuracy 123. 133 design of documentation 201. 133 nausea 269. 131 depression 123. 114. 155. 134 activities of daily living 125 advocacy 135 anxiety 133 assessments (nursing process) 12. 103. 144–5. 173. 285–8 objectivity behaviour and emotion 100 evaluation 169. 259 best practice 134 cognitive state 129. 136 language and jargon 136 legibility 135 leg ulcers 282 medication 127 mobility 125.

64. and protocols clinical pathways 80. 132 peripheral vascular disease 131. 40 effective documentation and nursing 31. 157. 47 occupational health and safety 164 pain management 134–6 professional communication 40 progress notes 63. 136 wandering 131 policies. 42. 135 unrecognised pain 130–2 validity 125. 40. 43 progress notes 63. 39. 40. 41. 132 peripheral neuropathies 131. 33–4. 73 quality control 39–41 . 212. 94 clinical reasoning 29 complementary therapies 110–112. 132 procedures for pain documentation 134–6 professionalism 134 quality control 136 reliability 125. 19. 213. 41. 252. 43 coaching 37–8 clinical reasoning and 23. 262 policies. 218. 36. 85. 133 social issues 125. 43 codes of professional practice 32. 164. 43 attitudes of staff 35. 146 systems model and 211. 76 restraint 138–41.313 Index pain management (continued) Parkinson’s disease 46 pathways see clinical pathways PEG nutrition 285–8 performance appraisal 181. 152. 16 accountability 43 accuracy 33 advocacy 33 analysis and 32 assessing the system 36–7. 31. 226–8. 87. 43 nursing-care plans and 48. 10. 41. 63 physiotherapy assessment 12. 127. 130 values and value judgments 134. 113. 282 nutrition 130 objectivity 201 osteoarthritis 131. 145. 37–9. 67. 93. procedures. and protocols (continued) political factors 8. 34. 33. and protocols professional communication 31–43 see also professionalism understanding documentation 8. 57 professional practice 32. 43 ethics 32–3. procedures. 43 legal requirements and 32 management and organisational issues 32. 187. 35. 201–2. 43 auditing and 32. 34–5 implementation 35. 24. 66. 42. 36. 133. 41. 121 incident reports 145. 43 evaluation 40. 91. 125–30. 40. 25 codes of ethics 32–3. 43 education and 30. 92. 130. 156. 183. 35 gap analysis 39–41 holistic nursing 33. 38–41. 153. 43 individualising care 38 initiative and innovation 34. procedures. 36. 155. 35–8. 143–4. 39. 42 evidence-based practice 39 feedback 38–9 funding and 31. 191 peripheral vascular disease 131. 14. 33–4. 39–41. 27–8 privacy see confidentiality and privacy problem-intervention statements 48 problem-oriented documentation 68–9. 165 nursing-care plans 45. 131. 42. 70 procedures see policies. 24. 42. 132 peripheral neuropathies 131. 154. 132 permanency of documentation 5. 234 numeric rating scales 119. 84. 32. 188. 42 leadership 34. 130 signatures and designations 135 sleep patterns 125. 182.

43 research and 32. 85. 34. 72. 81. 59 communication see professional communication complementary therapies 111. 55. 108 clinical pathways 79. 67. 227 timeliness 34 understanding documentation 3. 66. 33. 191 standards of practice 2. 33–4. 72 communication 63. 40 nursing-care plans and 45. 10. 188 exercise 252 faecal incontinence 252 incentive program 187 leg ulcers 280 occupational health and safety 164 quality improvement 10 restraint 148 volunteer program 259 word-processing 197 abbreviations 65. 60. 38 see also professional communication programs behaviour and emotion 98. 77 restraint 138. 68. 67. 77 audits 64 behaviour and emotion 77 best practice 60. 76 electronic documentation 76 emotional aspects 77 ethical issues 67. 113. 7. 35. 13. 25. 90. 65. 142 staff issues 188. 69 effective documentation and nursing 63. 68. 94 clinical reasoning and 19. 71. 14 activities 259 behavioural modification 170. 38–40. 64. 33. 28. 67 accuracy 64. 71. 74 access 66. 73 corrections 65 ‘DAR’ charting method 70 dates and time 65 education 64. 216. 59. 222. 190. 244 understanding documentation 2. 43. 175 incident reports 153. 73. 54. 70–1. 67. 50.314 Index professional communication (continued) programs (continued) professionalism reflection and 32 regulatory requirements 40. 67. 64. 116 design of documentation 208 evaluation 40. 258. 34. 215. 74–5 evaluation 69 . 239. 33–4. 66. 92. 107. 69. 9. 27. 74. 154. 148. 210. 70. 75–6 consent 74 continuity of care 64. 234–6 employee-assistance program 186. 58. 73. 51. 41. 43 progress notes 63. 43. 5. 235. 66 blank spaces 65 charting-by-exception 66. 29 codes of conduct 9 codes of ethics 32–3. 238 pain management 134 professional practice 32. 64. 43 risk management 41–2 systems model and 32. 238. 65. 105. 141. 218. 76 accountability 63. 64. 73 confidentiality 74. 236. 68. 119 continence 256 diversional therapist 257 educational 11. 77 archiving 75 assessments (nursing process) 63. 157 multidisciplinary teams 31. 11 validity 32 values and value judgments 32. 64. 237. 259 progress notes 63–77 complementary therapies 110. 121. 37. 223. 114– 115. 213. 9. 75. 47–8. 257. 115. 8. 43 codes of professional practice 32. 17 systems model 209. 68. 42. 73. 74.

90. 75–6 systems model 212. 57. 66. 65 systems model and 211. 118. 212. and protocols file management 75–6 frequency and quality 66–8 focus charting 68.315 Index progress notes (continued) protocols see policies. 76–7 nursing-care plans and 67. 64. 244 understanding documentation 3. progress notes accessibility 7. 113. 66. 67. 82. 70 professionalism 63. experience of nurses quality control and improvement clinical pathways 89 complementary therapies 111. 213. 208 destruction of 6 . 102. 94 clinical reasoning 26. 67. 76. 71. 29. 234. 59. 103. 64. 76 ‘SOAP’ charting method 68 social issues 77 source-oriented health records 71–3 spiritual aspects 77 standards of practice 63 storage 66. 117. 74 management and organisational issues 63. 121 credentialling of staff 182. 15. 116. 112. 178. 83. 90. 71. procedures. 85. 72 narrative progress notes 68. 73 holistic nursing care 71 incident reports 74–5 individualising care 71. 84. 65 referrals 69 research 76 resident-centred care 63 responsibility for 66 signatures and designation 65. 107. 200. 76 legibility 65. 121 design of documentation 193. 64. 75–6 medication 71 multidisciplinary teams 68. 53. 71 language and jargon 65 legal requirements 63. 58. 70. 30 complementary therapies 115. 60. 70. 73. 86. 74. 77 purposes of documentation 63–4 quality improvement 63. 60 pain management 136 professional communication and 39–41 programs 10 progress notes and 63. 75 validity 76 values and value judgments 74 publishing 11. 64. 115. 74–5. 212. 238–9 timeliness 67–8. 177. 61 restraint 148 staff issues 187. 203. 70. 155 accuracy of see accuracy of documentation’ behaviour and emotion 97. 9. nursing-care plans. 64. 204. 71. 71–3 nature of 66. 225 clinical pathways 89 complementary therapies 110. 68. 190–1 nursing-care plans 49. 183. 64. 69. 77 nursing interventions 67 objectivity 69 principles of documentation 65 problem-oriented documentation 68–9. 10 reasoning see clinical reasoning records see also clinical paths. 283 qualifications of staff see also education. 218. 190 understanding documentation 10. 73 interventions 67. 7. 201. 70. 70 funding 63. 72. 101. 66. 16 behaviour and emotion 97 clinical pathways 79. 68. 206. 50. 175. 202. 122 evaluation and evaluative criteria 180 incident reports 164 nursing-care plans and 47. 73. 224–6. 72 integrated progress notes 68. 74–5. 23. 74. 242–4 pulse rate 119.

241 accountability 139. 218. 29. 238. 10 research resident-centred care see also individualising care reflective nursing practice 13. 28. 257. 138. 213. 214. 132. 148. 154. 271 nursing-care plan 238 pain management 127. 86–7 complementary therapies 114 incident reports 156 leg ulcers 283 nursing-care paths 58 nursing-care plans 58 progress notes 69 ‘SOAP’ system and 69 stomal management 288 regulatory requirements (continued) reliability professional communication and 40. 212. 143. 223. 213. 177. 233. 130 systems model 232. 32. 148 staff appraisals 188 staff issues 184. 51–7. 258 regulatory requirements clinical reasoning and 19. 66. 216. 121. 213. 242 resident 77. 158. 176. 167 leg ulcer 281 nausea 268. 220. 139. 212. 258 pain management 125. 177 restraint 137–49 clinical pathways 80. 131.316 Index records (continued) referrals diabetes 263 discipline 189 educational 110. 132. 166. 14. 237. 140–1 . 26. 30 destruction of records 6 incident reports 156 management issues 15. 17 respiratory rate 175. 27. 43 progress notes 76 restraint 147 signatures and designations 120 systems model 211. 175. 191 staff selection 184. 43 restraint 138 staff issues 188 systems model 211. 238. 159. 215. 190. 221–4. 243 understanding documentation 3. 139. 242 clinical pathways 83. 94 clinical reasoning 29. 17 behaviour and emotion 98 clinical pathways 87 evaluation and evaluative criteria 170. 75–6 systems model 210. 188. 190 electronic 182 evaluation 171. 216. 134 permanency of 5 personnel 189 progress notes 75–6. 140 accreditation 141 accuracy 149 anti-discrimination rights 139. 131. 216. 172. 171. 59 progress notes 63 restraint 147 systems model 213. 185. 143. 115. 30 complementary therapies 111. 172. 86. 172. 227. 188. 161. 235. 165. 234. 238. 176. 185 stomal care 287. 228–34. 177 nurses’ attitudes 33. 189. 122 evaluation 178. 223 incident reports 151. 242 health 116. 157. 77. 82. 216. 179 nursing-care plans 50. 222. 113. 223 responsibility for 66 restraint 138. 173. 238 clinical pathways 92 complementary therapies 120 evaluation and evaluative criteria 172 incident reports 161 professional communication and 32. 214. 88–9. 83. 17. 189. 234 understanding documentation 6. 288 storage of 6. 85. 180. 145. 85. 15.

146 multidisciplinary teams 138 nurse/resident ratios 144 nurse registration bodies 138. 140–1 hazard-identification forms 145 holistic nursing practice 138 implementation 139. 139. 141 incident reports 145 interventions 143. 140–1 assessments (nursing process) 138. 145. 147 evaluation 138. 144. 140–1. procedures. 146 professionalism 138. 216. 140–1. 148 risk assessment 12. 87. 142. 143. 145 depression 142 education 138. 237. 147. 114. 26 signatures and designations complementary therapies 110. 159. 41–2. 144–5. 159 PEG nutrition 182 professional communication and 41–2. 143. 240 systems model 215. 139. 140. 142–4. 145 mini-mental 142 mission statement 138 mobility 142. 139. 142 protective assistance 138. 142. 140. 114. 120 design of documentation 206–7 pain management 135 progress notes 65. 147–8 effective documentation and nursing 147. 74–5. 141. 147 authority to restrain 145 behaviour 142. 76 . 148 falls 142 grievance rights 139. and protocols 138– 41. 148 signatures 142–3 sleep patterns 142. 112. 149 management and organisational issues 138. 147. 141. 148 occupational health and safety 139. 139. 145. 147. 147. 123. 145 benchmarking 147 building safety 147 care plans 138. 148 equipment safety 147 ethics 138. 146 chemical restraint 137 cognitive state 143. 145 auditing 145. 236. 141 objectivity 147. 145. 147 legal issues 138. 142 injury risk 46 leg ulcers 282 manual-handling risk assessment 12 occupational health and safety 141. 177 sexual health 12. 145 dates and time 143. 139. 147 medication 137. 43 restraint 141. 144. 141 physical restraint 137 restraint (continued) risk management policies.317 Index restraint (continued) appeal rights 139. 239 understanding documentation 12 safety risk assessment 12 sensory assessments 12. 142. 143. 116– 117. 144. 144 social issues 147 special senses 142 vision statement 138 clinical pathways 87 diabetes 265 falls risk 87. 146. 141. 147 comfort activities 145 communication 142 consents and authorities 138. 143–4. 148 qualifications of staff 148 regulatory authorities 138 research 147 resident-centred care 147 resident profile 142 resources 139–40 restraint review form 145 risk assessment 141. 144. 144. 155. 142. 148. 141–2.

188 legal aspects 184. 187. 114. 191 duty statement 183. 190. 127. 183. 182–6. 133. 17 stomal care 273–7 subjectivity 48. 12 absenteeism 186 accountability 187 accuracy 182. 185. 185. 191 complaints 182. 142. 185 education 187. 53. 58. 191 morale 187 occupational health and safety 181 performance appraisal 181. 188. 185 job sharing 187 key selection criteria 183. qualifications of staff assessments (nursing process) 110. 187 formative evaluation 188 grievances 190 handbook 184. 103 clinical pathways 86 clinical reasoning 19. 190–1 discipline of staff 181. 170. 183. 191 advertisements 183. 133 restraint 142. 187 appeals 184. 190. 77. 256. 199. 112. 191 information package 184. 69. 189. 189–90. 184. documentation of 181–91 see also nurses and nursing. 185 recruiting staff 181 responsibility 188 retaining staff 182. 101. 258 behaviour and emotion 98. 169. 12. 185 interviews 184 job analysis 182.318 Index signatures and designations (continued) research 120 restraint 142–3 systems model 222 understanding documentation 5. 112–14. 21–2 skin assessment 12. 183. 189 counselling 187 credentialling of staff 182. 185. 173– 5. 182. 130. 142 speech therapist assessment 288 spiritual issues 8. 189. 113. 57. 186. documentation of (continued) skills-acquisition theory 19. 155 staff issues. 185 affirmative action 181 staff/resident ratios 13. 115. 187. 171. 24 complementary therapies 110. 113–14. 257. 52. 186 human-resource management 181. 144 understanding documentation 12 source-oriented health records 71–3 special senses assessment 114. 188. 187. 6 staff issues. 191 selecting staff 181. 56. experience of nurses. 186–8. 60 pain management 125. 120 incident reports 156 nursing-care plans 46. 135 progress notes 77 restraint 147 understanding documentation 8. 201 anti-discrimination 181. 191 position description 183. 9. 185 attrition of staff 182. 183. 256 sleep patterns ‘SOAP’ charting method 68 ‘SOAPIE’ system 48 social issues assessments (nursing process) 12. 50. 199. 265 behaviour and emotion 103. 144 staff-satisfaction surveys 188 standards of practice 2. 183. 186. 114. 131. 188 equal opportunity 181 feedback 185. 182. 191 social justice 182 staff-satisfaction surveys 188 summative evaluation 188 . 54. 104 complementary therapies 114 incident reports 155 pain management 125. 190 electronic documentation 182 employee assistance program 186 employment contract 185.

237 innovation 216 Internet 183. 216 professionalism 209. 236–8. 238. 235. 222. 244 reflection 214. 235. 218. 221. 234 regulatory compliance 211. 238. 212. 218. 223. 217. 212. 227–8. 38–40. 214. 228. 237. 233 interventions 241 jargon 222 leadership 216. 216. 214. 230 holistic practice 210. 216. 218. 236 implementation 211. 232. 239. 34. 213. 218 code of ethics 223 cognitive function 235 complaints 216. 244 accountability 216.319 Index summative evaluation techniques 170. 224. 216. 237. 213. 238. 244 handbooks 218. 236–9 duty of care 222 education 212. 244 career options 214. 213. 33. 222. 171. 220. 172. 234. 234. 240 effectiveness of documentation 214 electronic documentation 217 ethics 219. 229. 233 policies and procedures 211. 228–34. 215. 216. 222. 211. 234. 212. 214. 239–40. 227. 233. 215–19. 234 preparatory work 211–34 professional communication 32. 227 evaluation (of documentation model) 217. 216 change agents 215 Cinahl information 219 clinical governance 211–15. 213. 215. 226–8. 240 best practice 211. 215. 216. 231. 226–8 Medline 219 mission statement 220 multidisciplinary teams 219. 173. 212. 43. 239. 218. 231. 244 progress notes 212. 242–4 quality system 211. 219–21. 218. 218. 238 research 211. 213. 213. 227 professional development 215. 233 Cochrane Collaboration 217. 242 evidence-based practice 211. 220. 212. 223. 234–6. 235. 219–21. 222. 238 nursing team 215 objectivity 217. 214. 234–5 documentation essentials 212. 218. 218. 224–6. 213. 240. 232. 236. 228. 240 confidentiality 222–3 corrections 222 critical appraisal 217. 223 legibility 222 management issues 209–10. 242 attitudes of nurses 209. 232. 237. 213. 228. 233. 212. 210. 235. 216. 35. 212. 235 auditing 212. 214. 220 adult learning 236 assessment of the model 212. 213. 218. 233 occupational health and safety 223 philosophy of documentation 211. 238–9 publishing 212. 237. 224 learning from experiences 214 legal aspects 222. 220. 237. 210. 235 feedback 239 funding 211. 243 . 232. 239–42 assessments (nursing process) 212. 215. 239 evaluation (nursing process) 214. 238. 239. 244 nursing-care plans 212. 224. 241–2 benchmarking 212. 236. 223. 213. 221–4. 188 ‘sundowner syndrome’ 20 systems model for documentation 209–44 systems model for documentation (continued) abbreviations 222 accessibility 216. 234 reliability 232. 237.

8 continuity of care 3 corrections 6 data analysis 11 data collection 11 dates and time 5. 10 responsibility 6. 17 legibility 5 management and organisational issues 1–2. 10–11 best practice 5. 241 risk management 215. 216. 11 confidentiality 5. 177. 15. 10. 3. 8. 17 legal issues 3. 14–17 nursing-care plans 9. 75 understanding documentation 5. 16 accuracy 3. 216. 6 definition of documentation 2 designation 5 destruction of records 6 documentation not performed 15 duty of care 5 education 2. 11. 10. 13. 16–17 auditing 10. 10 food intake 12 funding 1. 8 assessments (nursing process) 12 attitudes of staff 4. 237. 15. 16 objectivity 5 permanency 5 praxis 13–14 professionalism 2. 11. 15. 53. 8. 13 blank spaces 6 care plans 9 codes of conduct 9 cognitive state 12 communication 3. 3. 11 benchmark standards 9. 14 purposes of documentation 3 qualifications of staff 10. 237. 15 typefaces 197. 4. 3. 10 reflective nursing practice 13. 11 evidence-based practice 5. 14 importance of documentation 3 incident reports 6. 7.320 Index systems model for documentation (continued) resident-centred care 213. 226. 6. 13. 8. 8. 17 implementation 3. 10. 11. 12. 17 evaluation 10. 220. 5. 15 nursing practice 9–14 management issues 14–17 multidisciplinary teams 2. 6–7. 199–200 understanding documentation 1–17 abbreviations 6. 4. 17 government regulation 15. 175. 9. 7. 14. 10. 9. 17 holistic nursing practice 9. 11. 7. 239 signatures 222 storage 224 understanding documentation and 3 validity 217. 219–20. 8 indicators 10 individualising care 9 key aspects 10 key terms 2 language and jargon 15 leadership 2. 5–6. 200 timeliness and time management behaviour and emotion 107 clinical pathways 84 professional communication and 34 progress notes 67–8. 228. 5. 14 . 3. 11. 17 research 3. 236 verbal culture of nurses 222 vision statement 220 understanding documentation (continued) teams see multidisciplinary teams temperature 48. 8. 9. 16 quality control and improvement 3. 236. 16 ethics 2. 4–5. 8. 7. 15 access 6 accountability 13. 5. 238 values and value judgments 216.

59 vision statements 111. 87 clinical reasoning 21. 17 storage 6 system of 3 time management 5. 279–83. 136 professional communication 32. 176. 53. 152. 269 urinary incontinence 274 urinary stoma 276 urinary tract infection 52. 286 word-processing programs 197 wound assessment 12. 83. 173. 12. 228. 12. 12 standards of practice 2. 7–8. 269 validity clinical pathways 81. 171. 226. 27 complaints 189 complementary therapies 120 consent 115.321 Index understanding documentation (continued) urinalysis 177. 119. 143. 237. 142. 176. 49 visibility of nurses’ work 47. 220 visual assessment 12 volunteer programs 259 wandering 131. 130 professional communication 32 progress notes 76 staff-satisfaction surveys 188 systems model 217. 174–5 nursing-care plans 49. 177 pain management 125. 38 progress notes 74 systems model for documentation 216. 176 verbal tradition of nurses 47. 277. 175. 289–92 weight 175. 236 understanding documentation 2. 238 understanding documentation 11 scope of practice 10. 82. 288 values and value judgments clinical pathways 81 evaluation 169. 58 pain management 134. 37. 23. 138. 15 signatures and designations 5. 85. 273. 6 sleep patterns 12 social issues 8. 9. 178 urinary assessments 178. 7–8. 114. 17 . 17 variance and variance analysis 80. 219–20. 116. 144 credentialling 191 evaluation 170. 175. 178. 177. 93. 94. 178. 15 validity 11 values and value judgments 2. 12 spiritual issues 8. 170. 84.




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and progress notes. Nursing Documentation in Aged Care: A Guide to Practice is written from a different perspective. nursing-care plans. If this is to be achieved. observations. Christine believes that documentation must be undertaken effectively and efficiently. 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. caring nurses are aware of the personal satisfaction to be gained from documenting their holistic and reflective nursing practice. 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. In addition to their ethical and professional responsibilities. With contributions from a range of experts. positive resident outcomes and excellence in documentation will be assured. 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. and cared for in accordance with the highest professional standards. and progress notes can allow nurses to share their knowledge. 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. Although this perception of documentation is understandable. She is currently a nurse educator who believes that older people must be valued. The title of the book is carefully chosen. This is more than a ‘how-to-do-it’ workbook. 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. care plans. In striving for the highest standards of professionalism in all that they do. this comprehensive evidence-based textbook explores the issues surrounding documentation and reveals the importance of professional communication within multidisciplinary teams. . nurses are increasingly recognising that documentation is a wonderful opportunity to record and reflect upon all that is good in nursing. If aged-care nurses are empowered and confident in their own abilities.Nursing documentation is often perceived as a tiresome chore. As another volume in Ausmed’s growing and popular ‘Guide to Practice’ series of textbooks and audiobooks. and skills—and thus make a crucial contribution to their own professional lives and to the quality of life of those in their care. respected. This book shows how nursing assessments.