Preface

This open access textbook is intended to guide best practices for documentation in the nursing and midwifery profession. This resource is designed for students in undergraduate nursing and midwifery programs, and addresses principles of documentation, legislation associated with documentation, methods and systems of documentation, and key trends in the future of documentation. Incorporated into this resource is legislation and practice standards specific to Australia.

 

About the Authors

This Australian edition was written and updated by:

Tanya Langtree, RN, PhD, MNSt, PGDipAdvClinN(NeuroSc), PGCertNSc(IntCare), CHIA, Lecturer, Nursing and Midwifery, College of Healthcare Sciences, James Cook University

Elspeth Wood, RN, MNSt, GCRM, GCTT(Ed), Lecturer, Nursing and Midwifery, College of Healthcare Sciences, James Cook University

 

Contact details

Dr. Tanya Langtree (@LangtreeTanya), tanya.langtree@jcu.edu.au, James Cook University, Bebegu Yumba Campus (Douglas Campus, Townsville)

Elspeth Wood (@sister_wood), elspeth.wood@jcu.edu.au, James Cook University, Bebegu Yumba Campus (Douglas Campus, Townsville)

 

Acknowledgments

This book is based on  Documentation in Nursing: 1st Canadian edition by Jennifer Lapum, Oona St-Amant, Charlene Ronquillo, Michelle Hughes, and Joy Garmaise-Yee. It has been extensively revised and updated, with new graphs, images and examples suited to the Australian context.

Our thanks to our colleagues who volunteered to review this text.

  • Dr Trish Burton, Senior Lecturer, Nursing and Midwifery, College of Healthcare Sciences, James Cook University
  • Michelle McElroy, Lecturer, Nursing and Midwifery, College of Healthcare Sciences, James Cook University
  • Amy McCrystal, Lecturer, Nursing and Midwifery, College of Healthcare Sciences, James Cook University

Book cover image by Eliza Bookall

Technical support team:

  • Sharon Bryan, Blended Learning Librarian, Library and Information Services, James Cook University
  • Alice Luetchford, Open Education Librarian, Library and Information Services, James Cook University
  • Deb King, Liaison Librarian, Library and Information Services, James Cook University

 

Customisation

This textbook is licensed under a Creative Commons Attribution 4.0 International (CC BY-NC) license except where otherwise noted, which means that you are free to:

SHARE – copy and redistribute the material in any medium or format.

ADAPT – remix, transform, and build upon the material for any purpose, even commercially.

The licensor cannot revoke these freedoms as long as you follow the license terms.

 

UNDER THE FOLLOWING TERMS:

Attribution: You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.

No additional restrictions: You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.

Notice: You do not have to comply with the license for elements of the material in the public domain or where your use is permitted by an applicable exception or limitation.

No warranties are given. The license may not give you all of the permissions necessary for your intended use. For example, other rights such as publicity, privacy, or moral rights may limit how you use the material.

 

 

 

 

 

 

 

 

 

 

 

 

 

License

Icon for the Creative Commons Attribution-NonCommercial 4.0 International License

Documentation in Nursing and Midwifery: Australian edition Copyright © 2022 by Tanya Langtree and Elspeth Wood is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.