By Albert Abrams
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Documentation philosophy, policy, and procedures Job descriptions, and duty statements Key aspects of the documentation process Team members should deﬁne the critical components of the documentation system, determine the type of documentation used, note what is used most frequently, who uses what, and why different components are used. Team members should note any critical incidents that have occurred in relation to documentation. Continuous qualityimprovement program, best-practice principles, and benchmarking Indicators Team members should identify the latest documentation indicators from research, journals, and professionals.
However, the organisation must also acknowledge that nurses have to deal with the day-to-day reality of apathy and low morale that is so common with respect to documentation. Management should therefore encourage enthusiastic nurses to take on the role of ‘coach’ in the workplace. indd 7 23/03/2004 12:04:41 PM 38 Nursing Documentation ability to ‘ … unlock potential to maximise performance’. In this sense, coaching is ‘helping [others] to learn rather than teaching them’ (Whitmore 2002, p. 8). ’.
Lesser quality than clinical reasoning In many instances, experienced nurses can consider that the care given in accordance with written nursing plans is of lesser quality than that provided by an experienced nurse who follows his or her clinical reasoning. ’ an NCP. The experienced nurse is also able to intervene in ways that reduce ‘anxiety and agitation in ways more ingenious than those suggested by the NCP’ (Aidroos 1991, p. 179). Constrained to follow nursing plans The difficulty with NCPs is that nurses can feel constrained to follow them—even though autonomous thinking and practice would actually be in the better interests of patients.