The Importance Of Documentation In Nursing
According to Johnson, B. B. (2011, p.8) nursing documentation has been reported as a core component of nursing care. He said that it is a prerequisite for quality care to facilities efficient communication and cooperation among health professionals as well as effective coordination. In this essay will discuss about the importance of documentation, the factors that affect documentation, common errors in documentation and the ways to improve documentation for nurses.
Nursing documentation is very important for nurses as well as patients. This is because it may be used as evidence to either incriminate or exonerate for nurses in case of lawsuits (Jefferies, Johnson, & Griffiths, 2010, p.113). For example from my case scenario, the morning staff nurse forgotten to record the NGT insertion procedure into Mr. Tan’s case file. This will cause her lack of evidence support in case of lawsuit due to no documentation was recorded if something had happened to Mr. Tan. Law, Akroyd & Burke, (2010, p.1228) had said that not documented work considered work not done. In this case, the morning staff nurse can be consider that she did not perform the NGT insertion. In other words, incomplete and careless documentation can indicate that nurses are not providing standard care that supposed to be done to patient (Blair & Smith, 2012, p. 162). Good documentation can ensure appropriate reimbursement and providing a database for planning future healthcare. So it is very importance for nurses to
56431 Unit 1
638 Words | 3 PagesThey 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
Examples Of Each In Healthcare
337 Words | 2 PagesAssignment – 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.
Nursing Case Memo
647 Words | 3 PagesDOI: 4/16/2012. Patient is a 29-year-old male technician who sustained injury when he was 25-feet up on a ladder when the ladder slid and he fell onto the pavement. He had an open reduction internal fixation (ORIF x 2) for a compound tibia fibula fracture and had hardware removal in 4/25/2013. MRI of the lumbar spine performed on 3/24/2016 revealed L5-S1 small right paracentral disc protrusion without significant spinal canal stenosis or neuroforaminal narrowing.
Inaccurate Reimbursement Analysis
109 Words | 1 PagesOverall, 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.
Tuskegee Study Violations
600 Words | 3 PagesAll 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
Proper Documeant: Article Analysis
415 Words | 2 PagesAs 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
Medicare: Inpatient Prospective Payment System
634 Words | 3 PagesThe 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 Report Evaluation
1761 Words | 8 PagesEvidence 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.
Nursing Peer Review Paper
795 Words | 4 PagesNurses not scanning things proper into the system for documentation. The underlying issues take systematic measures of serious side effects due to
Rhetorical Analysis: We Need More Nurses
1464 Words | 6 PagesThis issue is not only affecting the hospital, but also the patients. In the article “When Hospital Paperwork Crowds Out Hospital Care” by Theresa Brown argues that nurses have too much paperwork to fill out about their patients. Having too many paperwork takes away from the nurses getting involved with their patients. In my opinion, neither of the arguments are valid because they lacks supporting details .Even though Robbins and Brown are passion about their topic, they both did a great job using pathos
Medical Assistant Code Of Ethics
785 Words | 4 PagesAccording to the provision 3.4, nurses should have professional competence in nursing practice. Nurses should promote health and patient safety, reduce errors and create a culture of excellence. When errors occur, nurses should follow the institutional guidelines in reporting errors and ensure responsible disclosure of errors to patients. When error occurs, whether one’s own or an error of a coworker, nurse should not condone through silence or try to hide it. It is important to report the errors to the concerned authority to maintain a safe patient care environment.
The Pros And Cons Of Nursing Shortage
1785 Words | 8 PagesThis is important evidence because it gives us conditions and results of what can happen if patients get lower quality care. Patients’ are not having enough time getting checked up by a nurse, and nurses would miss some diagnostics. Patients are getting sick because of the poor care they are receiving from nurses. The care patients can get is affected by a nurse shortage, “Nursing workload definitely affects the time that a nurse can allot to various tasks. Under a heavy workload, nurses may not have sufficient time to perform tasks that can have a direct effect on patient safety.
Ineffective Nursing Communication
1038 Words | 5 PagesThey need to learn the various pieces and functions of communication in diverse areas of nursing. According to Garrett (2016), to maintain patient safety communication should be consistent, comprehensive, transparent, concise, and appropriate, consequently, leading to interacting and connecting with patients who demonstrated to improve results, reduce costs, and improve the patient’s understanding. A study conducted by Daly (2017), states that they are four themes nurses should utilize in their daily practice: 1. Prioritise people, 2. Practise effectively, 3.
Reflection On Communication In Nursing
701 Words | 3 PagesAccording to Patterson & Krouse (2015), It is important to transfer the message in a good way, for that the communication skills is one of the most important basic skills of nursing leadership. More than that, communication in nursing can make their job efficiently and help them to communicate with a wide range of people, including the patient, patient 's family, and healthcare providers. However, unlike bad communication, which increases nursing staff problem and can lead to worsening the patient health condition, a good communication saves time and reduces the problem of nursing staff in resaving and deliver the right information. Furthermore, communication is not only talking with the patient it’s also listening to what the patient 's family and healthcare providers are saying to collect more information that helps the nurses to save lives. In this paper, I will reflect my communication that goes well with one patient.
Patient Communication: Consequences Of Ineffective Communication
1853 Words | 8 PagesWhen the nurse fails to communicate successfully with patients, it costs. It costs in unnecessary pain, in avoidable deaths, in poor health outcomes and in the prolongation of
More about The Importance Of Documentation In Nursing
56431 Unit 1
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