PATIENTS CARE DOCUMENTATION AND NURSING CARE PLANNING (PRINCIPLES OF PATIENT)
SIGNIFICANCE OF THE CONCEPT
“Documentation is a set of documents provided on paper, or online or on digital or analog media, such as audio tape or CD; (Wikipedia >wiki-documentation).
Patient’s care documentations are very vital to the nursing profession for effective communication between the nursing professionals and other healthcare personnel nursing care documentation provides proof of care rendered and it is an important part of professionalism and a medico legal requirement in nursing practices.
Documentation helps to organize care effectively and the various stage to therapy can be well understood and followed accordingly. Patient care documentation helps to …show more content…
Patient’s care documentation is as vital as the care rendered, here the need to ensure proper and effective documentation of all procedure carried out on a daily basis.
IMPLEMENTATION ACTIVITIES RELATED TO THE CONCEPT
Nursing care patients care documentation involves all written or electronically entries which reflects all the aspect of patient care which are communicated, planned recommendations or care given to patients. There are various types of documentation of patient’s care which includes shift rotation report, patient’s progress notes, admission report, nursing care plan and discharge notes.
Shift rotation report is a written document of all the patient admitted in the ward of the end of a shift which is read to the nurses taking over the shift.
It provides a detailed account of the previous shift care rendered to the patient conditions. The patients progress note provide in real time the status of the patient’s condition and care given, it helps the nurse understands the patient condition better and care given at each stage of the patient’s …show more content…
The electronic health record is a very useful tool in the documentation of care for a patients as these uses the advancement in technology, thereby saving time and creating more time to focus on the patient care. It is important for nurses to be acquainted with the use of electronic health records to be able to derive the optimum use of the technology.
The nurse can only prove his or her professionalism in the documentation of his care to a patient. Although due to the cumbersome nature of documentation many nurses dread it while also it’s also important to note that nurse should not write illegibly making it difficult for others to read, all written documents should be clear enough to be read by any one, all patients present conditions should be documented and any change in a patient or family status should be noted. Nurse should ensure the use of objective data i.e. report exactly what happened and do not speculate avoid erasing a statement or writing over an entry. These helps us to maintain a high standard of practice in the current
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They should be hold accountable for any breach in protocols. • Present format for electronic documentation does not allow for comprehensive clinical documentation during follow-up visit. Efforts should be made to upgrade the electronic medical record system to the standard of that expected for a medical center and research institute. This is to allow for proper documentation according to the industrial standard, and easy retrieval of patient’s information for clinical research. There is a need to employ a clinical documentation improvement specialist (CDIS) in this
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.
c.Documentation should always show that standards of care were met. d.Be sure to document everything because the written report will have more validity later on than what you remember. 24. Which of the following is an active listening skill to use with a patient to ensure effective communication?
The resources above expanded on knowledge concerning the definition, evolution, proposed outcomes, research and the technology of meaningful use of the electronic health record. Nursing administrators, staff nurses, and nursing informaticists all perform an essential role in achieving meaningful use of the electronic medical record to improve patient care. Certain authors referenced other authors proving that the health information technology field is indeed a tightknit community. The resources were well written from highly credentialed authors and were, for the most part, easy to comprehend. All of these articles were written for the nursing professional with the exception of resource
All patients have the right to have their medical information provided to them in terms that they can understand. Nurses are supposed to be patient advocates and we must advocate and assist in educating our patients. This is so important since many patients are their own caretakers and need to have the knowledge and tools to care for
Evidence and Evaluation in Bedside Reporting 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. By associating bedside reporting there is an optimistic impact on the patient and their relatives.
Additionally, there is a reduced cost of healthcare for patients as less repetition in treatments and labs are done for patients. Nurse educators have a key role in educating nursing staff on requirements of electronic health records and assisting in a smooth transition. A modification to the HITECH Act to address documentation, may assist in better workflow for nurses. Modification could ensure that only pertinent information requires documentation and then healthcare facilities compliant with the HITECH Act could modify their policies to reflect the
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 shift reporting is used in many health care facilities to promote a beneficial handoff for both patients and nurses. This type of reporting is an important process in clinical nursing practice because it allows staff to exchange necessary patient information to guarantee continuity of care and patient safety. “Moving the change-of-shift handoff to the patient’s bedside allows the oncoming nurse to visualize the patient as well as ask questions of the previous nurse and the patient” (Maxon, Derby, Wrobleski, & Foss, 2012). The standardization of shift handovers was identified as one of the 2009 National Client Safety Goals from The Joint Commission (TJC).
The technology has help with the conversion of the paper medical records to electronic medical records. Medical records are an essential part that must be reviewed by primary care physician and specialist. This conversion has made it possible for doctors from all over the world to collaborate and find solutions to a patient’s problem. I work in the medical field and know fist had on the importance of having all records electronic and accessible to all that are involved with the patients care.
Assignment – There are five common purposes for medical records. List each of these purposes and provide an example of each in healthcare. Having good medical records is very important, for the proper care of patients. “Medical records can be used to manage healthcare, track healthcare, provide clinical data, meet regulatory requirements, and document healthcare” (Allen, 2013, P. 57). Without the proper documentation there is no proof that it was ever done.
As a nursing student I am taught how to document using special medical terminology, and the importance of documenting, however the article “Stay Out of Court with Proper Documentation” by Sally Austin confirms just how critical it is to be accurate, timely, and unbiased with patient documentation. Proper documentation not only helps keep the patient safe, but just as importantly protects the nurse should a lawsuit occur. Austin’s article defines the legal terms used in the more common lawsuit, negligence, involving nurses and how to avoid them. First, the patient must prove four things in order for a lawsuit to be deemed in their favor: A duty to the patient existed, a breach of duty occurred, the patient was injured, and lastly the injury