Royal Children's Hospital Melbourne (ORMS)

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

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.

I. Need: Direct my audience to understand the situation of the children suffering of cancer in St. Jude Children Hospital and motivate them to volunteer or donate.

As a biller or coder, if it is not documented, it didn't happen that needs to follow to be able to give an excellent service to every patients. Documentation is the key to have an appropriate health patients result including demographics, health issues, and billing. “Consistent and complete documentation in the medical record for every patient is an essential component of providing quality patient care. This documentation is required to record pertinent facts, observations and findings, and must meet certain compliance standards.” If not documented that is not necessary to give any further diagnosis

Documentation records is related to the quality of patient care provided. It signifies the primary communication among multidisciplinary caregivers for efficient and effective intial treatment, for continuing care, and for the evidence that care and treatment occure. Regulatory agencies use the documentation as a means to measure the quality of services before granting accreditation or certification to healthcare organiztions. Some of those agencies include:

Use at least two patient identifiers when providing care. Double checking of ID bands and ID/Driver’s license of patient if possible. Using labels to mark all materials /items needed for the procedures. A two person check off procedure must be implemented. Items requiring labeling include: patient records, signed consents, and all assessments, diagnostic tests and x-rays. Also included should be any item that is needed for the procedure (blood products, devices, and equipment). Using a matching system, so that all items in the procedure area are matched to the patient. The matching system must be completed by a minimum of two staff members. These staff members should include a qualified staff member, nursing staff involved in the procedure, recovery room staff, and discharge staff.

At this time, the surgeon inspects the wound and the team conducts the count without interruptions (Norton et al., 2012). Among other required charting documentation are the nursing outcomes or Perioperative Nursing Data Sets (PNDS). These outcomes are responsibilities nurses are expected to implement while a patient is in their care. One item of the PNDS states "the patient is free from signs and symptoms of injury due to extraneous objects" (Rothrock, 2015, p. 207). It is the responsibility of the OR nurse to make sure facility policy is followed to ensure that a patient does not leave the OR with unintentional items remaining inside their operational site or sites. If there is a situation where an item is not located and the patient is stable, the OR nurse should have the surgical field halt activities. The team should then locate the missing item. When found, activities can resume. If the missing item is not found, then other facility protocols, such as intraoperative radiograph are obtained and reviewed by a physician to determine the location of the item. All these steps should be performed prior to the patient being closed or removed from the OR.

In Joint Commission, the stated out the standards needed for an organization to be compliance with patient care and safety criterion for accreditation. In Nightingale Community Hospital, some of this policies and procedures are not rightly observed in all the units, example is the policy that clearly stated that verbal orders has to be verified within 48 hours is not being practiced in many units. Above all, the second quarter compliance was steady and of all quarters rated the best, but the compliance result for the third quarter were quite poor. Most of the policy needs revision and the standard needs improvement in other for the hospital to be in compliance. One of the policies that need to be implemented is the form the nurse that collects the order, the form has to signed, dated and placed outside of the patient's chart, bringing it to the knowledge of the physician that an action is requested from him in regards to the patient.

This where the patients information goes so it is easily found by the doctor to access it. Also is where the description of the events that happened of each visit with the patient and what has worked and what did not work as a solution. Also can find the patients contact information here.

Provision 4. Nurses should practice within the scope of practice and consult specialist as soon as needed and the nurse must collaborate care of the patient they care for

Gallbladder surgery is usually done in a hospital while you are under general anesthesia. The surgeon makes four cuts in your abdomen that are large enough for inserting the tools necessary for the procedure. A video camera is placed through one incision. This displays a video of your gallbladder on a monitor in the surgery room. Your surgeon performs the gallbladder removal while watching the video screen since he or she can't see inside your body. Your gallbladder is removed through one of the small incisions and then your bile ducts and surrounding areas are checked for infections and other problems before stitching your incisions closed.

“The Process Improvement in Stanford Hospital’s Operating Room” case has many issues when it comes to regards to its existing instrument provisioning process taking place within the Operating Room (OR) of Stanford’s Hospital. This process entails getting instruments ready for a surgery in the OR and the cleansing of these instruments afterwards; however, there are many problems that arise in this process.

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.

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.

When assisting the patient, the radiographers have to make sure they provide radiation safety not only for the patient but also for themselves. There are many different methods to providing safety. With the equipment and radiation dosage, highest KVp and the lowest mAs is used to provide the minimum amount of dosage required for the procedure. Furthermore, safety can be provided by reducing the amount of rime in radiation area, by putting as much distance between you and the radiation source as possible. When performing a portable examination stand at least six feet from x-ray source and wear a lead apron. The patient should remove any jewelry or metal accessories that may interfere with radiation procedure and both the technologist and the patient needs to wear protective lead shields for example lead gloves, aprons, skirts and thyroid shields to protect the other body parts from the radiation. It is advised to also always wear monitoring device at collar level. Lastly, the technologist uses immobilization devices to hold the patients when needed.