From the Research
Standard Template for Documentation
The standard template for documentation used by aged care nurses in Australia is not explicitly stated in the provided studies. However, the studies suggest that there are various documentation tools and templates used in aged care facilities, such as:
- Nursing care plans 1
- Advance Care Plan templates 2
- Quality of Australian Nursing Documentation in Aged Care (QANDAC) instrument 3
Key Components of Documentation
The studies highlight the importance of accurate and comprehensive documentation in aged care, including:
- Nursing assessments and care plans 4, 1
- Resident outcomes and evaluation of care 1
- Advance care planning and end-of-life wishes 2
- Medication management and medical treatment preferences 2
Electronic vs. Paper-Based Documentation
The studies compare the quality and quantity of electronic and paper-based documentation in aged care facilities, with mixed results:
- Electronic nursing care plans were found to document more signs and symptoms of resident problems and evaluation of care, but had a lower total mean quality score compared to paper-based plans 1
- Electronic documentation systems were found to be feasible and acceptable to aged-care workers, with 89.3% of participants supporting their introduction 5
Quality of Documentation
The studies emphasize the need for high-quality documentation in aged care, including: