Progress Notes | Nursing Documentation in Aged Care: A Guide to [PDF]

Outlines the purposes and principles of documentation; Discusses the need of progress notes and the frequency of entries

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Progress Notes

Progress Notes Read Online

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eChapter

Authors:

Jenni Ham, (/online/educator/1701293#echapter) Ann-Maree Conners, (/online/educator/1707268#echapter) Angela Crombie (/online/educator/1738109#echapter)

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Date Published: eBook:

Nursing Documentation in Aged Care: A Guide to Practice (/online/nursingdocumentation-inaged-care-a-guideto-practice-ebook749028)

Chapter 5 No.: Topics: Aged Care (/online/topic/aged-care), Documentation (/online/topic/documentation), Legal (/online/topic/lawethics)

(/subscription) Outlines the purposes and principles of documentation Discusses the need of progress notes and the frequency of entries Outlines methods of documenting progress notes Outlines ethical and legal complications involved in documenting progress notes Discusses the need for secure file management and electronic documentation Effective communication in aged care is vital to the quality of resident care. Documentation is used to communicate details of the nursing care provided and to inform others of any significant events. There are many legal requirements involved in progress notes and it must always be remembered that a resident's notes represent a permanent written record of that person's nursing care and management. This chapter aims to guide nurses on how to effectively and securely document progress notes.

Contents include Introduction Purposes of documentation Principles of effective documentation The nature of progress notes Responsibility for progress notes Frequency and quality of entries Common methods of documenting progress notes Problem-oriented documentation Focus charting Charting by exception Narrative progress notes Integrated progress notes Ethical and legal implications Confidentiality Subpoenaed notes Avoidance of disciplinary/legal action File management Electronic documentation Conclusion Previous Chapter (/online/nursing-care-plans-echapter-194) | Next Chapter (/online/documenting-behaviour-and-emotion-echapter-197)

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Jenni Ham (/online/educator/1701293) Clinical Pathways Jenni Ham is a registered nurse and midwife who holds a graduate diploma and a master's degree in health science. Since 1994, she has worked as a project manager and acting operations manager at the Collaborative Health Education & Research Centre (CHERC) of the Bendigo Health Care Group, Victoria, Australia. Jenni has extensive experience in the design and implementation of clinical pathways. Her research projects have included the design, implementation, and evaluation of clinical pathways in acutePrelims and rehabilitation settings and the design and implementation of clinical pathways in smaller ... (/online/educator/1701293) eChapter View Full Biography Added: 15/06/2009

Understanding Nursing Documentation

Clinical Reasoning

Professional Communication

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Angela Crombie (/online/educator/1738109)

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