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Nursing Documentation in Aged Care

Nursing Documentation in Aged Care by Christine Crofton
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Foreword - Rosalie Hudson

Documentation has come alive! In Nursing Documentation in Aged Care: A Guide to Practice, the drudgery and monotony are taken out of an important aspect of nursing that has become, for many, a dreaded necessity. Nurses will be inspired to take a fresh look at the many positive aspects of documentation and to enjoy the professional rewards of improved practice. The issues are presented in ways that reinforce current good practice, encourage reflection on practice, and offer new ideas to guide improved practice.

The rewards of good documentation are to be found not only in professional pride, but also in creating more time for resident care. The book is therefore timely in addressing the frustration expressed by many aged-care nurses: ‘How can we achieve a good balance between documentation and resident care?’.

The various models of documentation described throughout this book will help to identify the unique details of each resident’s care. What does this record convey about the care of this particular resident? Who is this person in the context of his or her significant relationships? It is this personal and relational emphasis that makes this book on documentation come alive.

The practical examples provided will inspire nurses with confidence to try new approaches. To allow for creativity and flexibility to suit local circumstances, a variety of options is presented. Each component of documentation is described and distinguished from others—showing clearly how to avoid the duplication evident in contemporary practice. Helpful case studies based on everyday experience make this an enjoyable book of practical learning.

Throughout this book, communication is the cornerstone of effective documentation. In communicating with their colleagues, nurses do more than merely record facts and details; they also evaluate responses to specific episodes of care and thus learn from one another. Good communication promotes continuity of care as each person takes up the story—thus capturing the essence of holistic care. By making explicit the link between the care and the writing, the documented record is a profoundly insightful expression of professional holistic care.

Nursing Documentation in Aged Care: A Guide to Practice challenges nurses to regard quality documentation as a reflection of quality care. Good documentation is presented as the key to evidence—not only for legal and regulatory purposes but also for improved professional practice. Evidence of quality leads to expanded knowledge, and provides a rich, fertile ground for future research. This book therefore has enduring qualities. It has the potential to influence the whole of aged-care practice.

Written by people committed to the cause, there is something in every chapter that will inspire nurses to replace outmoded habits and attitudes with innovation and clarity of purpose. The purpose of documentation is clearly articulated throughout the book—to communicate the essence of resident care in a way that encourages professional pride and paves the way for best practice to be achieved. Nurses are prompted to write their documentation in a way that makes nursing visible—thus placing on record the difference that good nursing makes to the care of residents.

Nurses will be encouraged by the enduring qualities in this important and timely book. It not only answers immediate needs but also promotes documentation in aged care as a model worthy of wider attention by all nurses.

Ausmed Publications; September 2004
354 pages; ISBN 9781597340205
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Title: Nursing Documentation in Aged Care
Author: Christine Crofton; Gaye Witney