Documentation is a vital aspect to Registered Nurses when providing care. It is a form of communication to which other healthcare workers are able to refer to when needing background information on person that they are taking care of and planning correct nursing interventions (Paan et al 2010, p. 2386). The purpose of this paper is to analyse the communication processes of documentation that occurred while I was on placement at Ananda Hope Valley Residential Care in a high care ward. This paper will encompass a description of the processes of documentation at Ananda Hope Valley Residential Care, an analysis of documentation and how documentation contributes to professional communication. This paper will also contain how documentation complies
…show more content…
I now have been on placement at a residential aged care facility and in a hospital in acute care and the way they document is completely different. In an aged care facility the progress notes are done when a event or incident has happened or if a problem occurs and in the hospital it is at the end of every shift and the nurse writes how patient has been trough the shift through a full body assessment. (College of Registered Nurses of Nova Scotia 2012, pp. 8 - 9). All nurses need to document duties that they have done when providing care to their residents, it show that they have done the duties that they have completed and also allows for the health care professional to take full responsibility for their actions and the choices that they have made within the care that they have chosen to provide and can be accountable for (College of Registered Nurses of Nova Scotia 2012, pp. 8 - 9). Nurses need to document every thing that they do when providing the care of the resident that they are caring for. When not documenting a event or incident that has been completed or that has happened makes it as nothing has happened as it only happened if it has been documented so that other health care professionals are able to be notified and know that it has been completed. …show more content…
The Competency standard 1.1, which is ‘Practices in accordance with legislation affecting nursing practice and healthcare’. This competency was not complied with due to that the documentation was not completed accurately with the medication chart not being documented fully, even though the documentation had been completed in the DDA chart if the resident went to hospital there would be no evidence of the administration of the drug as the chart would stay at the aged care home. Also the competency standard 6.3, which is ‘Documents a plan of care to achieve expected outcomes’. This competency standard was not completely adhered to based on that the nurse left information out when documenting the PRN medication and also when the medication chart did not have that the Endone was given to the resident prior to completing the cancerous
I now have been on placement at a residential aged care facility and in a hospital in acute care and the way they document is completely different. In an aged care facility the progress notes are done when a event or incident has happened or if a problem occurs and in the hospital it is at the end of every shift and the nurse writes how patient has been trough the shift through a full body assessment. (College of Registered Nurses of Nova Scotia 2012, pp. 8 - 9). All nurses need to document duties that they have done when providing care to their residents, it show that they have done the duties that they have completed and also allows for the health care professional to take full responsibility for their actions and the choices that they have made within the care that they have chosen to provide and can be accountable for (College of Registered Nurses of Nova Scotia 2012, pp. 8 - 9). Nurses need to document every thing that they do when providing the care of the resident that they are caring for. When not documenting a event or incident that has been completed or that has happened makes it as nothing has happened as it only happened if it has been documented so that other health care professionals are able to be notified and know that it has been completed. …show more content…
The Competency standard 1.1, which is ‘Practices in accordance with legislation affecting nursing practice and healthcare’. This competency was not complied with due to that the documentation was not completed accurately with the medication chart not being documented fully, even though the documentation had been completed in the DDA chart if the resident went to hospital there would be no evidence of the administration of the drug as the chart would stay at the aged care home. Also the competency standard 6.3, which is ‘Documents a plan of care to achieve expected outcomes’. This competency standard was not completely adhered to based on that the nurse left information out when documenting the PRN medication and also when the medication chart did not have that the Endone was given to the resident prior to completing the cancerous