Nursing documentation includes any and all forms of documentation by a nurse or midwife recorded in a professional capacity and in relation to the provision of nursing care. This video collection explains concisely what nursing documentation is and presents 20 fundamental principles of sound nursing documentation.
Nursing documentation is essential for good clinical communication. Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care. Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice.
An accurate written record detailing all aspects of patient monitoring is important, not only because it forms an integral part of the of the provision of care or nursing management of the patient, but because it also contributes to the circulation of information amongst the different teams involved in the patient’s treatment or care.
Australian Commission on Safety and Quality in Healthcare Standards : Structured clinical handover has been shown to reduce communication errors within and between health service organisations, and to improve patient safety and care, because critical information is more likely to be accurately transferred and acted on.
NSQHS Standards Icon 6 - Communicating for Safety - The Toolkit comprises a range of project management tools and resources to assist with clinical handover improvement and has been adapted for use in all healthcare settings.
Australian Commission on Safety and Quality in Health Care PDF - Communication errors are a major contributing factor in hospital sentinel events,and are the most commonly cited underlying cause of complaints about the Australian health care system.
Conflict, it occurs in any workplace, and always needs to be carefully managed. In many ways, there is a greater potential for conflict to occur in an aged care environment than in a number of other workplaces.
Impaired communication with difficult patients can lead to a vicious cycle of attacks and counteracts. You may inadvertently direct negative actions towards the patient, who in turn, may feel abandoned. This creates an ongoing cycle of poor communication. Effective communication is vital to breaking this cycle and moving toward solution focused actions.
Through various dramatised scenarios, this programme looks at a range of typical situations in an aged care environment where conflict between people occurs. In each case, several potential responses to the situation are examined and conclusions drawn about the most effective and appropriate ways to deal with them.
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