The essential beliefs and principles that influence our behaviour, decisions, and actions are referred to as core values (Montgomery, 2023). Effective communication and taking accountability are two values that I feel are the most important to me and throughout nursing and something I feel I can bring to the profession. These two values are essential when it comes to delivering person centred care and forming relationships with patients and families as a nurse. Personal and professional relationships all contribute to patient-centred care. As a result, attempts to enhance patient-centred care should consider the patients and their families (Epstein and Street, 2011).
Communication is a two process of an individual expressing information and
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Effective communication is critical during the numerous interactions that take place among healthcare professionals on an everyday basis. Staff must know how to speak effectively and work together in a multi-disciplinary team to ensure that appropriate information is passed on in a timely fashion. Patient safety is jeopardised if effective communication is lacking (Nadzam, 2009). One of the many ways healthcare professionals communicate with each other is record keeping. The Nursing and midwifery council code states within code 10.1 “complete documentation at the time of the occurrence or as soon as possible after it has occurred, recording if notes are written sometime after the event” (The Nursing and Midwifery Council, 2023) .Another way to remember this is if it hasn’t been written down it didn’t happen, I personally find this phrase very helpful as it reminds me of the importance of record keeping . When record keeping it is important, we use words and phrases our colleagues know and avoid using medical jargon. Code 7.1 in the NMC code states use terminology that your patients, coworkers, and the public will understand, by doing so will help miscommunication between healthcare professionals and patients (The Nursing and Midwifery Council, 2023). We should also ensure that all notes and records are in legible handwriting , dated and times and that we do not use …show more content…
Although, there was multiple patients suffering from delirium on the ward, when I went to check on this patient, I felt like my communication was being challenged a lot more as I wanted to explain to them that what they thought was there, was just their imagination whilst trying not to make them agitated. This effected my communication skills as I felt like the patient knew I was not sure what to say when they said comments about imaginary things, as my body language was different, and I felt more tense due to the subject of conversation being unpredictable. I feel like this effected my relationship with the patient as I was not comfortable enough to deal with the situation on my own. I also felt that if there were two nurses present and one had more clinical experience that the patient would feel more comfortable and would find it easier to calm down if they were feeling overwhelmed. Communication is vital in nursing for establishing trust and comfort, and it is the foundation of the nurse-patient relationship (Dithole et al.,
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.
Use the hospital or facility policy if there is a correction that needs to be made in the document. Do not scratch out, use liquid paper, or conceal any documentation. This makes the nurse look like you are falsifying
(2010). Johnson (2015) and Evans et al. (2012) discuss the overall process of implementation of a bedside report along with outcomes. Johnson (2015) however, additionally highlights Lewin’s change model in the study. Friesen, White, and Byers (2008) reveal issues with different methods of report and their implications and Racco (2014) discusses the bedside safety check process.
Medicine has changed in ways over the years that one might have never thought twice about having anything like that happen to them. People today have increased their knowledge overall about their health situations and how to treat themselves. Patients are stepping up and making decisions about their healthcare choices each day with physicians. And in this process it has turned out to be so important for people to understand what is truly being done before medical treatment is given. We have talked this semester about informed consent and how important it is that our patients understand the meaning of what they are having 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
Ms. Martin is a 14 year old female who presented to the ED after an altercation between her mother and she. She denies suicidal ideation, homicidal ideation, and symptoms of psychosis to nursing staff. At the time of the assessment Ms. Martin is calm and cooperative. She reports tonight her mother would not let her eat a pop-tart for dinner and she became anger and proceeded to hit her mother. Ms. Martin states she only gets angry at her mother and lashes out at her.
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.
It is essential that every person feels valued to maintain person centred care. Sanderson and Lewis (2012) noted that person centred care fosters patient involvement in their care delivery through working collaboratively with healthcare professionals. This permits them to engage with patients allowing them to make decisions through communication about their care. Healthcare professionals also do strive to treat the patients with dignity, respect and
Nurses not scanning things proper into the system for documentation. The underlying issues take systematic measures of serious side effects due to
The overall synopsis gives prompt for the need of utilizing standardized handoff tools as well as negotiation of patient transfer among departments. As nurses, the transfer of information efficiently is the ultimate responsibility to aid in communication for success rather than contribute to its failure. This could potentially be a barrier to improvement if many nurses fail to adopt the initiative. In preparation for a future career in nursing and being first line in patient safety, it is a personal responsibility and goal to implement efficient communication in my own professional practice. With efforts to promote effective communication, success among the transfer of information to eliminate issues will be exemplified through
Another core value is caring. Caring is central in nursing practice. It includes such characteristics demonstrated by the nurse as empathy, connection to, and being with the patient. All these characteristics lead to sensitive, safe, and patient-centered care. Next core value related to nursing is
Communication is the process of transferring of information. Viswanathan (2010) says communication can take many forms of verbal and non-verbal methods which may include speaking, writing, gestures, expressions, listening and body language to name a few. All of these things should be taken into consideration to ensure an effective means of sending and receiving information. How and what information is sent may not be received in the same manner intended.
Documenting the patient's medical information, reduces medical errors that can become a life or death
“Effective communication is one of the most vital components of healthcare” (Crouch et al. , 2013). It is through effective communication that nurses are able to discuss their client’s needs and provide all the necessary elements for increased healing both physically and mentally. Nurses are able to form a therapeutic relationships with their clients through various forms of communication and provide the best care needed for not only the client but for the family members of the client as well. One of the many ways to establish a strong therapeutic relationship with patients is to make the patient feel at ease with humour. Friendliness and laughter are important factors when forming trust between nurses and patient.