Nursing Documentation Essay

Record-keeping and documentation are a hugely important part of nursing practice that unfortunately is often overlooked. Good record-keeping is in fact an essential element of being a good nurse. This assignment will discuss the importance of record-keeping in the healthcare setting. Record-keeping is vital for three main functions of nursing. It facilitates communication, promotes safe and appropriate nursing care and meets professional and legal standards (CRNBC 2008). These purposes and other important functions of record-keeping will be described in this assignment. The professional and legal implications of poor record-keeping will also be outlined. The topics will only be briefly and broadly discussed due to word count

The issue of documentation of patient care has received considerable attention in the last few years for an array of reasons. Trends in society such as increased consumer education, informed consent, expectation for healthy baby, and an increasingly litigious society all contribute to increased risk management awareness on behalf of healthcare facilities. Risk management deals with the probability that a given risk will result in poor outcome and then attempts to reduce probability. El Centro Regional Medical Center (ECRMC) has identified nursing documentation as an area of greatest risk

Confidentiality is critical for nursing professional to understand and undertake. If a nurse did not keep a

Health information is an important source of information and evidence when the services provided are communicated in legal and professional documentation. It is a documentation which is a legal requirement and a record of the beneficiary’ care as well as a communication vehicle between other disciplines and providers. It not only ensures the services provided to individuals but is a crucial tool to support reimbursement of services and a basis for research. Incomplete and improper documentation potentially may lead into a denial of payment for services as well as question’s the quality of care provided.

Summarise the main points of legal requirements and codes of practice for handling information in health and social care.

An important aspect of nurse practice is communication as it is the process of transferring information, feelings and ideas (RCN, 2015). It also provides knowledge based on identifying behaviour patterns, establish a relationship between nurse and patient and it is also

The patient has the right to every aspect of their care and this includes being involved in the change-of-shift bedside report. The purpose of this study is to identify the benefits of bedside report and its impact on patient safety, satisfaction, and quality of care. The participants of this study were randomly selected and of varying ages. The methodology utilized in this study is a qualitative and quantitative research. The results of the study will determine the benefits of incorporating bedside report into nursing care.

As a carer or healthcare provider, some of our obligations are to make sure that information is: utilized reasonably and legally, utilized for restricted, particularly expressed purposes, utilized as a part of a way that is sufficient, applicable and not unnecessary, accurate, kept for no more than is totally fundamental, handled by information insurance rights, kept protected and secure and not exchanged outside the UK without sufficient insurance (Walsh, 2011, p.88).

Communication is any form of expressing and receiving of messages between individuals. The importance of Communication in the nursing profession is to maintain high quality care for the patient but also maintain effective collaboration between professionals. Boykins, D (2014) states that the “registered nurse is expected to communicate in various formats and in all areas of practice”. Various formats include speaking to patients and coworkers as well as utilizing appropriate protocols and systems to effectively communicate regards to patient’s status.

Written communication in healthcare system comprises of care plans, daily reports, handover sheets ,medication sheets in general ,(record keeping). These clinical records are essential skills of communication that a nurse should be able to write as well as extracting vital information from which to provide relevant and precise care. This makes continuity of necessary care possible and fulfils one of NMC’s (2008) core principles of the code of working with others to protect and promote the health and wellbeing of those in nurse’s care and obligation to ensure total and effective information is communicated to your colleagues concerning people in your care (NMC 2010). These records help to increase answerability to the part of the nurse if the nurse is aware of this will be more considerate knowing that any mistake will come around. In addition these records help as the basis for decision –making for nurses and multi-disciplinary team of which the nurse

Nurses utilize writing every day in clinical practice, making the attainment of professional writing skills an important goal for students. Scholarly writing is form of communication which exchanges health information amongst professionals and consumers. Professional nursing literature is formatted according to the American Psychological Association (APA) formatting standards. Producing well-written nursing documentation or publications helps nurses enhance their professional respectability along with the discipline’s respectability. Writing helps nursing practice become more efficient, patient-centered, and evidenced-based because it encourages critical, creative, and holistic thinking. It is recommended for registered nurses to have a solid foundation in scholarly writing, literature review, and APA formatting if they wish to contribute to nursing publications. This paper aims to reflect on the importance of professional writing throughout a nurse’s career.

At a practice level, the importance and guidance of the Code of Conduct, Code of Ethics and NPA are demonstrated on a daily basis with regard to the issues of documentation, informed consent and open disclosure, and confidentiality. With respect to documentation, nurses must be able to document patient assessments and responses in an accurate, comprehensive and confidential manner and record all observations objectively. Informed consent and open disclosure are also major legal issues nurses face daily. It refers to the communication between the patient and health professional that results in the patient's agreement to undergo a specific procedure and requires that the patient has thoroughly understood the procedure, implications and risks prior to giving written consent.

Documentation plays a vital role in research, education, quality assurance and reimbursements for both patients and providers (Okaisu, Kalikwani, Wanyana, & Coetzee, 2014, p. 1). The importance of documentation is not lost on any RN, but continuity in what is recorded and what is absolutely necessary to have in a patient’s record is not always met.

Ineffective nursing documentation compromises patient safety and can result in serious or even fatal errors. Nursing documentation is essential to practice and is defined as everything entered into a patient’s electronic health record or written in a patients’ record (Perry, 2014). The goal of effective nursing documentation to ensure continuity of care, maintain standards and reduce errors (Perry, 2014). Nurses are accountable for their professional practice which requires documentation to effectively reflect the care that clients receive. The College of Nurses of Ontario (CNO) states that nursing being regulated health care professionals are accountable for ensuring that their documentation is accurate and meets the practice standards (College of Nurses of Ontario, 2009). Effective documentation strategies to reduce errors include; documenting in a timely fashion, using correct abbreviations and spelling, correcting documentation errors appropriately and ensuring that handwriting is legible. The purpose of this paper is to explore these strategies in greater detail with the goal of improving the care nurses provide to their clients to enhance safety.

Oral communication in healthcare is a continuous process and is extremely important for all those involved. Nurses relay relevant information to patients and their family, they are also responsible for updating the physician about the condition of their patients as well as nurse to nurse reporting. This communication is a fundamental part of the nursing process and can result in either quality effective care or ineffective care caused by lack of information. Written communication between the doctors, nurses, patients, and patient families can occur in a number of forms whether handwritten nursing notes or electronic medical records. Both forms are permanent