Bedside Reporting Paper

For this vSim assignment, I had to repeat the scenario three times before obtaining 100% on it, since I had forgotten about a few important steps when assessing my patient, and in my second try, I had forgotten to check the patient 's electronic health record even though I had already fixed my previous mistakes in the assessment. Three of the most important things I had to do differently in this scenario were to ask the patient about allergies to maintain patient safety before administering any drugs ordered, use the incentive spirometry to improve breathing and educate her about it since she had a hard time breathing due to pain, and educate the patient about wound care at the end before discharging her. Performing the procedures I missed in

In the leadership in care delivery course, we were assigned to a hospital to perform clinical hours and provide care to four patients. Additionally, the purpose of this paper is to explain and provide examples on how our patient care included the concepts of Quality and Safety Education for Nursing (QSEN) competencies, delegation, handoff reporting, and a reflection of the clinical experience.

Patient safety experts have demonstrated that “patient safety increases when teamwork and collaboration skills are taught and empowered; when teamwork and collaboration are not present, medical errors will result” (Creasia & Friberg, 201, p. 348). As a nurse, it is imperative to collaborate with other interdisciplinary members in health care and also strive to research and implement evidence-based practices. Evidence-based practice is necessary to “ensure the highest quality of cost-effective care and the best patient outcomes” (Fineout-Overholt, 2011, para. 16). With a collaborative and innovative attitude on safe health care practices, an increase in patient safety and effectiveness of care will

Research studies show that evidence-based practice (EBP) leads to higher quality care, improved patient outcomes, reduced costs, and greater nurse satisfaction than traditional approaches to care.1-5 Despite these favorable findings, many nurses remain inconsistent in their implementation of evidence-based care.

During my clinical day three, I demonstrated entry-level competence in professional nursing practice in caring for patients with multiple and/or complex unmet human needs. I addressed safety needs, safety in medication administration, effective communication, and surveillance for my patients. First, I addressed safety needs my ensuring the appropriate safety measures were implemented for the patients. Some of the safety measures included, wearing non-skid socks, wearing a yellow armband which indicated fall risk, keeping the bed in lowest position, two side rails up, bed locked, and the call light within reach.

Appropriately modified de-identified data for the 56431 attendee at the various clinics was used for this analysis.

To evaluate the change, results were monitored on a monthly basis which was not sufficient to reach the goal of 100% compliance. The initial change was effective in increasing the compliance rate from 68% to 95.6%. An additional PDSA is needed to meet the goal of 100% compliance. This can be achieved with additional reporting on a weekly basis, with a focus on individual staff or primary care teams. This will allow for individual coaching. Without coaching, individual barrier or gaps cannot be identified.

The patient is a 52 year old female who presented to the ED via EMS with bizarre behaviors. Per documentation neighbors found the patient screaming in her house. Per documentation LEO found the patient attempting to drink a closed bottle of alcohol hand sanitizer fluid. Patient presents with disorganized thoughts and irrelevant subject matter when asked questions about behavior upon arrival. Nursing staff was asked about status before the assessment and reports improvements in the patient bizarre behavior.

Overall, incomplete documentation and delinquent medical records cause inaccurate reimbursement and results in inaccurate gross revenue to the hospital. It can have a negative impact on the hospital budgeting and financial planning process for the hospital. It is for this purpose that every healthcare institution should be purposeful on reviewing the accuracy and completeness in clinical documentation, no matter the cost. Even though, for most physicians, most of their time is focused on the actual care of the patient and there is little to no time to devote to extensive documentation, it is imperative to understand patient care includes both the one-to-one attention and the documentation of said treatment.

Patient whiteboards were upgraded and are use to the fullest, they serve as a communication tool between hospital providers and as a mechanism to engage patients in their care, whiteboard use could improve teamwork communication as well as patient care and awareness of their care team, admission plans and duration of admission, and significantly improve patient overall satisfaction. The bedside nurse manages writing and updating the whiteboard each day using a templated board, the displayed information includes day and date, the names of the patient, bedside nurse, and primary and attending physician, family member 's phone number, diet, pain management and mobile numbers for Nurse, Charge Nurse and Nurse Assistant. This simple strategies is driving our thresholds to our benchmarks at an accelerated

Bedside reporting assist nurses with a chance to improve patient safety and increase patient collaboration in the arrangement of care. There is also less care correlated to inaccurate or deficiency of information because the report process includes actual patient apparition. Increased staff approval with bedside reporting supports teamwork and supports accountability.

Peer review is a process established to evaluate individual standards and quality of care issues (Harrington & Smith, 2015, p. 1). According to the Texas Department of State Health Services (DSHS), all hospitals are required to implement a program of incident-based peer review and comply with the reporting requirements established by the Texas Board of Nursing (BON) (Bearden & Shelton, n.d.).

Under state law, a patient may pursue a civil claim against physicians or other health care providers, called medical liability or medical malpractice, if the health care provider causes injury or death to the patient through a negligent act or omission (Malloy, 2015). In North Carolina, The Nurse Practitioner has different risks and premiums. The recommendations are to obtain as much coverage as the provider can afford, but no less than one million (Krauss, 2004). Some employers will carry the liability insurance but they strongly recommend obtaining one 's own policy for additional coverage. For family practitioners with no obstetric practice: a 115-percent increase to $9,000 per

Points of care solutions are medical diagnostic testing or documentation done at the patient 's bedside. At my work we us point of care documentation, meaning that the nurses do their documentation in the patient 's room. Research shows that point of care solutions “reduces inefficiencies, decreases the probability of errors, promotes information transfer, and encourages the nurse to be at the bedside” (Duffy&Kharasch, 2010). However, point of care services has been reported by patients to make them feel alienated for their care providers because the nurse 's attention is on their charting and not the patient (Duffy&Kharasch, 2010). This has the potential to “compromise the nurse-patient interaction” (Duffy&Kharasch, 2010). With changes in

Communication is described as the interchange of information, thoughts, and feelings between individuals using dialog or other methods (Kourkouta, & Papathanasiou, 2014). Communication between patients, nurses, and other healthcare professionals can influence the patient outcome subsequently, understanding what establishes an effective communication will be beneficial for nurses and other healthcare professionals. Having the skills to articulate efficiently exists beyond having verbal skills. According to Wright (2012), to establish effective communication, a nurse should develop the use of nonverbal cues such as body language, demonstrating active listening skills to facilitate assurance that the interaction remains successful, and having