The complexities of documenting clinical information in long-term care settings in Australia

Clinical nursing documentation, written, verbal or supported by technology, is being affected by both the worldwide "information explosion" and budgetary constraints. In Australia, the necessity of documenting complex care needs and treatment plans in older adult care settings has become more imperative because funding levels and sources are frequently tied to these documents. As a consequence, the statutory requirements for documentation have become a significant driving force in shaping nursing practice. Although the value of quality documentation is or should be recognized, the seemingly vast amounts of time required inevitably distracts nurses from what they see as their primary purpose-the provision of direct patient care. Older adults who are frail are among the most complex clients requiring services in what is traditionally a poorly resourced sector. Under-funding frequently impacts on the staff skill mix, resulting in low levels of senior, highly qualified, and skilled staff. These factors impact the quality of the documentation and possibly the usage of the information itself. This article will provide an overview of the issues related to documentation of clinical information in older adult care settings with particular reference to some of the "unique" inefficiencies inherent in the Australian system.