Communication Is Needed For Any Important Job

Records are kept to promote, provide and improve the care provided for patients. They are also used for audits and quality assurance carried out by the Care Quality Commission (CQC).

Record keeping provides evidence of any interaction or intervention involving a patient. It needs to be comprehensive enough to determine that the nurse has fulfilled his/her legal and professional duty of care (Griffith 2007).

It is important records are accurate, up to date and clean with no chance of being misunderstood because it could lead to the wrong treatment or sending information to the wrong person or address which could lead to a random person seeing the confidential information. Advantages and disadvantages of maintaining confidentiality and managing information: Advantages Disadvantages It could bond trust between a patient and the staff taking care of the patient. Easy to break the trust and relationship between a patient and the person taking care of them when breaking confidentiality. All information about the patient is kept secured and safe, so it will not be seen by another person.

While there is a learning curve associated with moving from paper charting to on line documentation of nursing care, there are a few measures that can decrease the amount of time spent in front of the computer. In order to avoid time spent frequently logging into the system there are security features that can be used such as finger print technology and employee badge swipe technology. Instead of writing notes on paper and then recording in the computer nurses are encouraged to complete documentation at the patient bedside at the time of patient care

Written Communication Skills for Nurses: Written communication plays a vital role in healthcare settings because it provides the facility with a permanent record of the residents and their care plans. Flym stated as a nurse written

Paper charts can cause doubt when there is a lack in the signature, or when staff is unable to read related to illegible writing. Other issues can be; abbreviation and not timing and dating the entry contribute to inaccurate charting. Paper chart can lead to a lack of clarity with orders which can affect emergency care for critical patients. Paper charts limit the ability to prompt nurses to check on areas such as medication interactions and dosage contributing to poor patients’ outcomes. Paper charts of previous admission are kept in storage places, making it necessary to find these charts which can take time. This again delay patient care and could result in poor patient outcomes. Paper charts have an increase risk of improperly filed, leading to an increase threat of a lost chart. In a case of a medical emergency, this could be catastrophic for the patients. Another barrier is the inability for interdisciplinary members to view the paper chart. To view a paper chart, it will need to be scanned or emailed to the interested party, which again can delay treatment for the patient. The last point is, “over time paper charts will naturally deteriorate in storage” (Csiszar, J., & Media, D., n.d).

A lot of things have evolved when it comes to patient records in the medical field. In medical facilities the patient records use to be in paper form. There would be multiple pages of patient information, doctor

Today’s healthcare is changing, and more hospitals are commencing to go paperless using computers for both medical records and charting. Computers are widely accepted, in personal and professional settings. It is an essential requirement for computer literacy. Numerous advances in technology during the past decade require that nurses not only be knowledgeable in nursing skills but also to become educated in computer technology. While electronic medical records (EMR’s) and charting can be an effective time management tool, some questions have been asked on how exactly this will impact the role and process of nursing, and the ultimate effects on patient safety and confidentiality. In order to

As healthcare continues to evolve, it is necessary that care provided is documented efficiently and without error. This documentation should be readily available whenever needed. The electronic health record is a database that provides a reflection of all care provided. This database would be beneficial to healthcare professionals providing care to new and frequent patients. Assessment documentation, physician orders, progress noted, and results review will be beneficial when comparing current assessments

Communication is a critical skill for every profession--including nursing. For this week, write a post describing the kind of written and oral communication that you do at work. How much of your typical work day is occupied with speaking and writing? What kinds of documents do you compose? Recall a time when you experienced a problem at work as a result of poor communication. What were the causes of and possible remedies for the problem? How do you think studying technical writing would help you in your current and future work?

Prior to the onset of tablets, the patient chart was the pillar of hospitals for decades. With the patient chart, assessing prior medical records was a huge concerned to most hospitals. As such, physicians found themselves repeating medical tests and procedures resulting to poor outcome. But with the tablet replacing the paper chart or the clipboard, patients can now fill out forms and questionnaires electronically

A medical record, whether in a physical record or an electronic form is a legal document that should “reflect an accurate chronology of events” (Brous, E., 01 Feb., 2009, para. 2). Without exception, every entry must be dated with a year, time recorded with either am, pm, or in military time, and the medical record should be signed with a last name and the doctor’s status. Furthermore, the medical record should read like a book; as well as paint a picture of the patient so that others who reach the chart will know what the doctor saw and did to the patient. Doctors that document about the patient and what the

For many people in the health care field health records are an everyday part of life. Health records have many different purposes. For instance, some of the primary purposes of health records are patient care delivery, management, support, patient self-management and financial and administrative processes (Sayles, 2013). Patient care delivery is one of the most important aspects of health records. Health care professionals document the what, when, who, why, and how of patient care into health records. This information is used to determine how a patient is doing and what needs to be done to ensure the patient is taken care of. Most non-verbal healthcare professional communication is done in the health record. Health records are a place to collect

When I started working at my current facility, we were just transitioning to electronic medical records. I was eager to learn about the new change that will occur with patient charting. Some of the nurses who had been practicing for years had trouble with the new changes that will be implemented into the patient charting system and did not understand how this new change will improve patient

Accurate nursing documentation is paramount to increased level of care for a patients that are admitted into hospitals, referred to other providers or discharged from care. An accurate medical record is by far the most reliable source of information on the care of a patient. The proper documentation by nurses prevents errors and facilitates continuity of care.