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

Communication and the Manager
’s Job

Assertiveness and the Manager
’s Job

Renal Nursing A Practical Approach

Ageing at Home Practical Approaches to Community Care

Complementary erapies in Nursing and Midwifery

Keeping in Touch with someone who has Alzheimer’s

Geriatric Medicine a pocket guide for doctors, nurses, other health professionals and students


Living Dying Caring life and death in a nursing home

Caring for People with Problem Behaviours


Practical Approaches to Infection Control in Residential Aged Care


Nursing the Person with Cancer a book for all nurses

Caring for the Person with Faecal Incontinence a compassionate approach to management



website: <www.ausmed.com.au>
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

Contents
Chapter 8 Documenting Complementary Therapies 109
Sue Forster
Chapter 9 Documenting Pain Management 123
Michael Cully
Chapter 10 Documenting Restraint 137
Sue Forster
Chapter 11 Incident Reports 151
Adrian Cross
Chapter 12 Documenting Evaluative Criteria 169
Sue Forster
Chapter 13 Documenting Staff Issues 181
Sue Forster
Chapter 14 Effective Design for Documentation 193
John Collins
Chapter 15 A Systems Model for Documentation 209
Christine Crofton and Gaye Witney
Appendix 1 Faecal Incontinence 249
Janette Williams
Appendix 2 Behavioural Management 255
Robyn Daskein
Appendix 3 Diabetes 261
Victoria Stevenson
Appendix 4 Nausea 267
Robyn Millership
Appendix 5 Stomal Care 273
Heather Hill
Appendix 6 Leg Ulcer Management 279
Sue Templeton
Appendix 7 PEG Nutrition 285

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
DocumPrelimsFinalProofs.indd 9 26/03/2004 1:06:24 PM
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.
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.

Dr Rosalie Hudson is a registered nurse who holds bachelor’s degrees in applied science
and theology, a master’s degree in theology, a graduate diploma in gerontic nursing, and
a PhD. After a long and distinguished career in clinical and academic nursing, including
12 years’ experience as the director of nursing of a 50-bed nursing home, Rosalie is now
a private consultant in aged care and palliative care, and an honorary senior fellow in
the School of Nursing, University of Melbourne. Rosalie has presented and published
numerous papers and articles internationally on the subjects of spirituality, palliative
care, dementia, pastoral care, and ethics at the end of life. Rosalie edited Dementia
Nursing: A Guide to Practice (Ausmed Publications 2003). She has also co-authored
two other Ausmed books, and has contributed chapters to several others. Rosalie enjoys
family life with her husband, adult children, and grandchildren.
xi
Foreword
DocumPrelimsFinalProofs.indd 11 26/03/2004 1:06:24 PM
DocumPrelimsFinalProofs.indd 12 26/03/2004 1:06:24 PM
Preface
Christine Crofton and Gaye Witney
A guide to practice
Nurses constantly complain that they have insufficient time for proper
documentation. In many ways this is understandable. Nursing is
essentially about
caring, and many aged-care facilities today are under-
staffed and under-resourced. In
these circumstances it is hardly
surprising that many nurses
feel that caring comes first and
documentation comes second—that
they have time to care or time to
write, but do not have time for
both.

and reflective nursing practice. In this respect, nurses are increasingly
recognising that documentation
is a wonderful opportunity to
record, share, and reflect upon
all that is good in nursing.
Documentation is more than a
tiresome chore. Comprehensive
and accurate documentation shares astute nursing insights, reflects
the excellence of holistic aged-care nursing, and provides a record of
the professional and personal support that nurses provide every day to
residents and their families.
Nursing Documentation in Aged Care: A Guide to Practice
is
therefore written
by and for nurses who believe that documentation is
of the utmost importance as a guide to nursing practice
—practice that is
ethical, professional, holistic, and reflective.
The purpose of documentation
In documenting aged care, nurses are recording and communicating
information about many important matters. These include (among others):
• care needs—the identification and assessment of the needs of those
in their care;
‘Documentation is of the utmost
importance as a guide to nursing
practice—practice that is
ethical
,
professional
,

the interaction (and possible conflict) between real nursing experience
and administrative documentary requirements. This is followed by a
chapter on ‘Professional Communication’—stressing the significance
of documentation as an exercise in effective communication between
professional colleagues in a multidisciplinary team.
Having canvassed these broad introductory issues, the book then
moves on to discuss three important forms of nursing documentation—
‘Nursing Care Plans’, ‘Progress Notes’, and ‘Clinical Pathways’.
This is followed by chapters on some selected clinical issues that
can provide documentation problems—‘Documenting Behaviour and
xv
Preface
DocumPrelimsFinalProofs.indd 15 26/03/2004 1:06:25 PM
Emotion’, ‘Documenting Complementary Therapies’, ‘Documenting Pain
Management’ and ‘Documenting Restraint’.
The book then moves onto a consideration of the documentation
of wider managerial and administrative issues—‘Incident Reports’,
‘Evaluative Criteria’, and ‘Documenting Staff Issues’.
The second-last chapter of the book provides some helpful advice
on ‘Effective Design for Documentation’—with hints on how to design
documentation forms that are functional and effective.
The final chapter in the main body of the book draws everything
together in a comprehensive ‘Systems Model for Documentation’. The
model presented here puts many of the topics of earlier chapters into
an overall context. In doing so, it provides guidance to clinical nurses
and nurse managers in how to go about establishing a comprehensive
documentation system that promotes positive attitudes and outcomes with
respect to this vital aspect of aged-care nursing.
Following the main body of the book, several case studies are
discussed in the appendices. These short case studies present common

documentation in an increasingly difficult work environment. If performed
with pride and professionalism, nursing documentation in aged care can
truly be a ‘guide to practice’.
xvii
Preface
DocumPrelimsFinalProofs.indd 17 26/03/2004 1:06:25 PM
DocumPrelimsFinalProofs.indd 18 26/03/2004 1:06:25 PM
About the Authors
Adrian Cross
Chapter 11
Adrian Cross holds a diploma in production engineering, a degree in arts, and a graduate
diploma in ergonomics. Adrian worked in industry for 25 years, dealing with quality
assurance and occupational health and safety. He then worked in the public service
for 15 years specialising in facilities
’ management—including the management of
hospitals and aged-care facilities. Adrian is now a lecturer in aged-services management
and occupational health and safety at Victoria University and Kangan Batman TAFE
(Melbourne, Australia).
Pamela Bell
Chapter 5
Pamela Bell is a registered nurse who holds a bachelor of arts degree and a PhD. She
was formerly the professor of nursing at Charles Sturt University (South Australia) and
is now an honorary senior research fellow in the Faculty of Nursing at the University of
Technology (Sydney, Australia). Pam is also a registered psychologist who supervises
interns undertaking pre-registration requirements at the College of Psychological
Practice, Sydney. Before becoming an academic nurse, Pam had many years of clinical
practice in Victoria and New South Wales. Having grown up in northern Victoria, Pam
has an excellent understanding of the problems facing rural health practitioners, and she
successfully led the Charles Sturt University component of a joint venture with Monash
University in forming the Australian government

—including senior management of aged-care
facilities. She is currently a nurse educator and is completing her master
’s degree in
education and training. Christine believes that older people must be valued, respected,
and cared for in accordance with the highest professional standards. If this is to be
achieved, Christine believes that documentation must be undertaken effectively and
efficiently. If aged-care nurses are empowered and confident in their own abilities,
positive resident outcomes and excellence in documentation will be assured.
Angela Crombie
Chapter 6
Angela Crombie is a registered nurse who holds a bachelor’s degree in nursing and
master’s degree in health science. Angela also holds additional qualifications in
psychiatric nursing and workplace assessment and training. She is employed as a
xx
About the Authors
DocumPrelimsFinalProofs.indd 20 26/03/2004 1:06:25 PM
research officer and nurse educator with the Collaborative Health Education & Research
Centre (CHERC) of Bendigo Health Care Group (Victoria, Australia), specialising in
research and education on aged-care issues. Angela has been involved in a number of
research projects, many of which have included the design and development of care
pathways in a variety of settings. Some of these projects have included: a regional
dementia management strategy; health assessments under Medicare schedule items;
asthma management in rural Victoria; health surveillance in the elderly using a health-
surveillance screening instrument; and home and community care best-practice
projects.
Michael Cully
Chapter 9
Michael Cully is a registered nurse with a degree in education, a graduate diploma in
education and training, and a master’s degree in nursing studies. He is a nurse educator
at Ipswich Hospital (Queensland, Australia) with interests in mental-health nursing,

Jenni Ham
Chapter 6
Jenni Ham is a registered nurse and midwife who holds a graduate diploma and a
master’s degree in health science. Since 1994, she has worked as a project manager and
acting operations manager at the Collaborative Health Education & Research Centre
(CHERC) of the Bendigo Health Care Group (Victoria, Australia). Jenni has extensive
experience in the design and implementation of clinical pathways. Her research projects
have included the design, implementation, and evaluation of clinical pathways in acute
and rehabilitation settings, and the design and implementation of clinical pathways in
smaller rural hospitals. Jenni and her colleagues at CHERC have demonstrated that
clinical pathways can be implemented successfully for patients with complex needs.
Jenni’s work has achieved national recognition, as demonstrated by frequent invitations
for her to present at workshops and conferences.
Heather Hill
Appendix 5
Heather Hill is a fellow of both the New South Wales College of Nursing and the Royal
College of Nursing, Australia. She is also a life member of the Australian Association
of Stomal Therapy nurses and the World Council of Enterostomal Therapy. Heather
has been involved in clinical practice and education in stomal nursing since 1981. She
has lectured extensively and has written papers for nurses, allied health personnel,
doctors, and laypeople. Heather has presented at numerous international conferences
and seminars and was the onsite clinical co-educator for the inaugural stomal-therapy
course conducted by the Singapore Ministry of Health and Singapore Cancer Society.
Joanne Hope
Chapter 5
Joanne Hope graduated as a general nurse from the Royal North Shore Hospital
(Sydney, Australia) in 1973. She also holds a diploma in nurse education and a master
’s
degree in education. Joanne is currently working as a nurse administrator in the aged-
care sector. Her past positions in aged care have included executive nurse advisor,

Robyn Millership is a registered nurse and registered midwife who holds diplomas in
nursing education, intensive care, and ward management. She also holds a certificate
in palliative care. Robyn has worked in palliative care as a nurse consultant for more
than 15 years. Her background is diverse including clinical practice, intensive care,
administration, and education. Robyn is passionately committed to providing excellence
in symptom control for patients with terminal illnesses. She believes that most people
can achieve what seem to be impossible goals if they are provided with optimal
symptom control, knowledge, encouragement, and support. Robyn was a recipient of a
Victorian Nurses Care Award in 1994. She is currently a nurse consultant in palliative
care at the Peter MacCallum Cancer Institute, St Vincent’s Hospital and Caritas Christi
(both Melbourne, Australia).
Patsy Montgomery
Appendix 7
Patsy Montgomery is a registered nurse, registered midwife, and stomal therapist who
holds a bachelor
’s degree in educational studies. She is co-founder and consultant
xxiii
About the Authors
DocumPrelimsFinalProofs.indd 23 26/03/2004 1:06:26 PM
for the Gastrostomy Information Support Service, president of the Peninsula Ostomy
Association (Melbourne, Australia), and the coordinator and clinical nurse consultant
for the Abbott Nutrition Service, Victoria (Australia). Patsy
’s role is to provide a support
service for tube-fed people, their families, and their carers when patients are discharged
from hospital into the community. This includes information and help for managing
enteral tubes and equipment, advice about methods of feeding and nursing care, and
information regarding supplies of formula, equipment, and pumps. Patsy also provides
education and practical ‘hands-on training’ for gastrostomy-fed people and carers.
She also provides in-service training, workshops, videos, and literature for healthcare
professionals.

About the Authors
DocumPrelimsFinalProofs.indd 24 26/03/2004 1:06:26 PM