Importance Of Documentation In Nursing Information System

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DOCUMENTATION
Documentation plays a very important part in the healthcare delivery system. It serves as a communication tool for all health care providers to ensure that there is continuous, safe, accurate, quality healthcare for each patient. Documentation also serves as protection for nurses, in case of any claim in regard to an alleged act of negligence or malpractice. When documenting nurses should always use factual, consistent, accurate, objective and subjective to ensure the patients progress and health care can be monitored. Nurses should always provide a rationale for any decision made. Jargons should be avoided when documenting to prevent any misunderstood communication.
Can you imagine a paperless hospital? A hospital that doesn't
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The use of a nursing information system such as our Bar Code System, will document types of medications used in hospital settings catering to patient’s needs. It will also provide checks and double checks which is a valuable tool because it maintains the five rights of medication administration, notification are at the nurses finger tips, errors and warnings are readily available, allergy checking is automatically performed, dose checking and other relevant clinical data are…show more content…
Unfortunately proper assessment of a patient is not done due to the short staff of medical practitioners. What if I told you there is a way every patient can get a compassionate medical practitioner who would understand what is wrong with the patient and thoroughly explain what is happening, why it is happening and how to treat it all in the comfort of their home or somewhere convenient to them. This is very possible and it can be done by using Telehealth. Telehealth is using machine that can provide video conferencing with the doctor and patient. The machine is well designed and equip with high definition camera and audio that allows the medical practitioner to assess the patient. One might ask how a machine can allow an assessment via video conferencing. This is done because attached to the machine is an otoscope which is not like the traditional one, this otoscope has, installed in it high definition camera that can zoom in and other and capture clean digital pictures of the patient’s eyes or even the patient’s throat. Another equipment that is attached to the machine is a then stethoscope which provides the practitioner with audio of the lungs, heart, and

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