Patient's Care Documentation In Nursing

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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
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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
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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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