Documentation In Nursing Documentation

An incomplete and falsified medical record demonstrates that care given was incomplete (Huston, 2006). Clearly, incomplete documentation in patient clinical records can contribute to inaccurate quality and care information. Not only that, patient may also take legal actions. Furthermore, it can cause a nurse to lose the license. There are consequences of inappropriate or inadequate documentation.

In nurse’s perspective, the poor and inconsistent of pain assessment can lead to unrelieved pain and reduce patient mobility, resulting in complications such as deep vein thrombosis, pulmonary embolus, and pneumonia (Ed. Caltorn, 1997). Postsurgical complications related to inadequate pain management will affect the length of hospitalization; the risk of readmissions, and increase the cost care of treatment. Somehow, a poor documentation of current status pain assessment will delay the intervention and responses to the care plan (Gordon, 2005). Thus, to overcome this situation in clinical practice, The American Pain Society (2005), created the phrase “Pain: the fifth vital sign” to increased awareness of the important in pain management

This case study highlights the conflict that can arise between nurse practitioners (NP) and physicians due to lack of proper communication, poor physician attitude, and lack of respect. Clarin (2007) labels these items as barriers that inhibit effective collaborative care and ultimately hinders the goal of medical institutions. In this case study, the way that the physician treated the new NP encourages other physicians in the practice or staff members that it is acceptable to treat another provider in this manner. This poor behavior will continue the cycle of disrespect and distrust when we should be collaborating with one another in the healthcare field. Not to mention, creates an unhealthy work environment.

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.

According to him one can make an error of omission (failure to act correctly) or an error of commission (acted incorrectly). By applying the failure mode effect analysis (FMEA) to determine what part of the "safety net" that failed. An error can be prevented. However, the practice of medicine, pharmacy, and nursing in the hospital setting is very complicated, and so many steps occur from "pen to patient" that there is a lot to analyze. errors can also occur as a result of poor oral or written communications.

The medical records are required by federal, non-government and state and local agencies. The medical records assist in communication among health providers and other multidisciplinary team in nursing and health care settings. Thus, the provision of planning and implementing patient health care and other recommended treatment based on the information presented in the medical records. In the nursing perspective, the patient assessment, including the initial, shift assessment of the patient is a significant purpose of the nursing documentation. Consequent to the planning of health care, implementation of care and evaluation of the treatment provided.

Due to overload, nurses and practitioner experience reoccurring errors, which place patients and healthcare workers’ life, at risk. As a result, the healthcare system and practitioners become aware of the need to review patient care. Some countries have seen the need for a change but focus on external factors rather than caring. However, Watson implies, that the state of been different is to focus on competent, compassionate, knowledgeable, and caring nurses and health practitioners. (Watson.p.471).

As well, both health care and patient care processes practiced some routinely tasks to be performed, which make the health care staff more fatigued and more distracted, hence, more errors may be induced. Medication

Descriptive statistics of the frequencies, means and percentages of medical errors occurrence as a result of each cause are presented in Table 4.3. The staff who participated in this study reported that their team often or frequently encountered medical errors because of lack of equipments (52%), lack of training/experience (47%), lack of teamwork skills (44%), communication breakdown (45%), Lack of planning, failure in decision making, conflict within team members, failure in patient’s information sharing (37%), lack of collaboration within team members (36%), conflict with other teams (31%), delegation of authority (28%), weakness in controlling team members(26%) and lack of following guidelines

Excessive workload demands that the person cannot meet. Long work hours, excessive patient load. Quantitative overload is defined when there are too many things do in the allotted time. Competing priorities Demands that exceed the person’s ability (e.g., task is too complex, too demanding). Or qualitative underload, when the tasks that the nurse is required to complete are too simple, not challenging enough Process of dying, assisting the dead, death, resuscitation, and taking people off of life support Time pressure Readiness, preparedness Human services Certain types of tasks Fulfilling expectations Sense of being under time pressure, sense of not being able to have a break, being on call Subjective feelings of constant readiness, preparedness because something might happen.