Nursing Notes And Discharge Analysis Paper

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

When I arrive to the Trauma ICU 4800 unit, all of the nurses were already being followed by other students. The nurse in charge had me follow several different nurses, so I was able to observed several different patient cases. The first patient had received a triple bypass open-heart surgery. The patient had received a creatinine blood test. The patient had a dialysis machine next to them, which was used to function as the kidneys since the patient’s kidneys were not functioning correctly. Also, the patient’s body temperature was lowered from having a taken cool liquids so the nurses were keeping him warm with a bair hugger, which was a machine that helped regulate the patient's’ body temperatures.

The system was confusing at first, but once I started clicking around and exploring, it became easier to understand and locate the information I needed. I was able to find information like why the patient was there, vital signs, labs, allergies, past medical history, and medication schedule. After doing assessments I was able to document those findings and observations made during the assessments. For this task, I could improve by taking my time to chart and not chart findings vaguley. For my next clinical day, my goals for this task include taking my time while documenting, and to remember not to leave my patients information up on the screen if I walk

This process paper will evaluate the complex relationship between disease pathophysiology and how it has progressed to the patient’s current state of health. It will include a comprehensive discussion of chronic and acute problems leading to the patient’s hospital admission, a complete description of interrelationships and pathophysiology for all medical diagnoses, a comprehensive discussion of the client’s signs and symptoms and results of all diagnostic studies to the underlying pathophysiology, and a comprehensive listing of all medications ordered at the time of admission with explanations of why each was ordered and identification of the most common side effects which may

Accuracy of recordings and ease of understanding of patient information in medical records play central role in quality of

In an effort to improve nurse to provider communication, an SBAR template (Situation, Background, Assessment, and Recommendation) is being implemented as a format for nurses to share relevant patient information during a triage visit. The project will be developed with input from the Clinical Nurse Supervisor, Information Management Specialist, Staff Nurses, and Providers. A nurse to provider SBAR template will be created and intergraded into the current electronic health record system for utilization during triage. Eventually a policy can be developed requiring the SBAR template to be used by all registered nurses during triage to improve communication between the nurse and provider. In order to limit the scope of this project due to time restrictions, the researcher will pilot the new tool exclusively on one team at the White City VA SORCC. The nurse and provider on the team will utilize the SBAR template for one week during all triage visits. At the completion of the week, the team will determine the feasibility of utilizing the SBAR template, as well as provide recommendations for its modification. Any modifications will be implemented, and an additional pilot study will be performed for one week. The will allow for two PDSA cycles to present to the Director of Out-Patients Services who has the authority to approve or deny the SBAR template utilization by the Registered Nurse during triage.

There are many types of data collected, such as, Demographic, financial, socioeconomic, and clinical data are collected from patients so that the healthcare providers of services to the patient are able to assess the history of whatever disease the patients is suffering from and how is to be treated. Data collection in the facility is well organized in a way that promotes shared assessment, treatment and communication. Nurses and front row staffs collects raw data’s from the patient, and. The Heath Information Manager and team are the facility are responsible in analyzing and presenting the data collected in a meaning and easily understandable way to served the specific purposes for which it was collected. Examples of such data are, patient’s name, height, weight, gender, allergies, and third party

Nursing, as the largest health care profession in the United States, plays a tremendous role in health promotion and delivery of care. From the 2.7 million employed registered nurses to the current Deputy Surgeon General of the United States, nursing infiltrates all aspects of healthcare (Bureau of Statistics, 2015). Therefore, as a profession, nursing must understand the intricacies of the Patient Protection and Affordable Care Act (ACA) and within its framework develop strategies to “advance nursing, health, and healthcare through education, clinical practice and research,” (Young et al, 2017). This paper aims to review portions of the ACA as it pertains to nursing, and offer an example of nurse practitioner innovation in practice.

In evaluating the outcome and measuring the success of the team, we went back to the objective that was established to determine if these were met within the timeline specified?

One the most important issues facing nursing these days is the changing healthcare insurance industry. I saw how these changes affected staff firsthand. I worked at Quincy Medical Center for three years until it closed in December of 2014. The Affordable Care Act led to cuts to Medicaid supplemental payments for the uninsured and has forced many hospitals to reduce staff or close like Quincy Medical Center. This is a concern for nurses because under current federal regulations there are no specific requirements for nurse to patient ratios. Multiple research studies demonstrate that lower nurse-patient ratios save both lives and money long term. For example, hospitals that routinely staff with 1-to-8 nurse-to-patient ratios experience five additional deaths per 1,000 patients than those staffing with 1-to-4 ratios, according to the Journal of the American Medical Association. Higher nurse to patient traditions lead to higher burnout

Clinical data is vital signs; the patient's vital signs are taken by the healthcare professional either before or

The use of data is essential for nursing professionals to care for patients. Clinical data is used to support clinical decision making. With the introduction of technology and the electronic health record (EHR) and the amount of available data is insurmountable. It is estimated that nurses spend up to 50% of their work day recording, seeking, processing, and managing data, Access to clinical data has the potential to be very powerful for nurses, however data must be accurate, complete, reliable, and accessible to be of value (Hebda & Czar, 2013). Through the use of standard nursing language and the alignment of nursing sensitive quality measures the nursing profession will define the work of nursing through data and improved outcomes (Dykes

After discharge from the GEM unit, 39 (83.0%) of patients returned home, 1 (2.3%) returned to residential care, 2 (4.7%) went to a hospice, 3 (6.4%) went to another rehabilitation hospital, and 2 (4.3%) returned to acute care. After discharge, 26.1% of patients had a single readmission within 3 months, 10.9% of patients required multiple (≥2) readmissions and 66.0% patients had died (n=28) at the time of follow-up (roughly 1-2 years post discharge). (Table 2).

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.