Strategies Of Nursing Documentation For Promote Patient Safety

As nurses in the health care system, we are the one that is been looked upon with high expectation to provide safety and quality care. Even more the nurses that are present and future in the field of evidence base practice and nursing informatics. With this development knowledge, nursing are expected to perform at a certain level when it comes to engaging in electronic health record and patient care. Gone are the days where paper records was used because it doesn’t sufficiently meet the needs of the health care delivery system today.

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

Risk management along with other staff members work together to specifically identify and delineate the areas of deficiency chosen for improvement. The criteria for proper documentation are determined through reference to accepted nursing standards or principles of risk reduction in medical record documentation. Baseline data from medical record audits should be obtained before building an education program. This data will be compared to data collected after the education program on documentation, to establish its effectiveness. Often the baseline data will already exist. The medical record reviewer or nursing committee who identified the deficiencies will have months of data collected, quantifying the extent of the deficiency.

Casarett, D., Spence, C., Clark, M. A., Shield, R., & Teno, J. M. (2012). Defining patient

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

In provision 3.4 it discusses that nursing is consistently reviewing policies, and looking at ways to increase patient safety, reduce errors, and promote patient health. Also, it discusses that nursing educators teach and ensure competency in in new nurses, before they are able to practice on their own. Some ways nurses can help in this process is, by following current safety standards that help reduce errors, such as: checking patient armbands and verifying birthday and patient, name with the patient. Other ways are, ensuring adequate staffing is provided, based on the acuity of patients, in an effort to reduce the nurses stress. Also as a nurse reporting when errors occur, so that policies can be either reviewed or new policies can be put in place to help prevent the error from occurring again. Student nurse can help by speaking up when they are in need of further teaching on a matter, asking for help when unsure on how to perform a task they have been given, and by taking in as much knowledge as they can during their nursing school

Safety is a small measure that can make a big impact on a patient in the clinical setting. In some cases, it can even cost patients their lives. According to the Online Journal of Issues in Nursing, safety is defined as a tool to minimize risk of harm to patients and providers through both system effectiveness and individual performance (Barnsteiner, 2011). Safety problems can range from the nurse not knowing how to work certain equipment, or the nurse recording values wrong because he or she is distracted. Either way, these safety issues impact the clinical setting in a negative way. In order to have a functional, safe clinical environment, time and money must be spent to keep the hospital in working order and the nurses in the correct mindset.

Errors pervade in our lives whether it is our home, in our workplace, or in our society. The effects of healthcare errors have impacted all our lives either directly or indirectly. Patient safety and quality care are at the core of healthcare system which strongly depends upon nurses. “To achieve goals in patient safety and quality, thereby improve healthcare, nurses must assume the leadership role. Nurses need to ensure that they and other healthcare providers center healthcare on patients and their families. Even though the quality and safety of healthcare is heavily influenced by the complex nature

While reading chapter 11 of Conceptual Foundations: The Bridge of Professional Nursing Practice it definitely touches on why charting is important for the patients care but also why it is important to the nurse themselves. As a nurse everything must be documented from washing ones hands to the take of medication that has been administered to that patient. Reason being is that it is evidence the nurse completed and did everything that was required for the patient’s well-being. Due to the fact that the nurse documented

Patient safety is one of the top priorities for health care organizations. Numerous conversations and evidence bases research have been conducted, with the aim of pinpointing factors that can be controlled to improve and preserve patient safety. This essay will explore one area that health organizations can control that has a direct correlation to patient safety: providing optimal staffing levels of nurses. Exploration of potential problems that touch on this subject will be discussed: morality and falls, ethical responsibility, fiscal data, as well as

This code is present so that nurses’ can enhance their capability to promote safe and quality nursing care for patients in need. Thompson et al. (2005) states that recognizing and interpreting a physician’s plan in the workplace, and the ability to identify and implement possible solutions to communication- related issues that places patients’ safety at risk, are methods of promoting patient safety, as stated in the Vaismoradi et al (2011) article. The success of implementing these methods explains why nurses are advanced in delivering quality nursing care in comparison to other clinicians (The Canadian Nursing

Counselor contacted mother to cancel session scheduled for 09/08/17. Mother discussed her safety plan for the upcoming hurricane with counselor and updated counselor on TC's well-being. Mother also talked with counselor about her financial problems and the worries she has regarding her finances. Session date and time TBA.

Such system failures as “poor documentation” was researched and described by Blair and Smith (2012) in the article “Nursing Documentation: Frameworks and Barriers”. Such frameworks of nursing documentation as narrative charting, clinical pathways, and focus documentation were described. This article provided literature to effective documentation and emphasized barriers to safe documentation. The goal of the project was to find appropriate frameworks for legal and correct documentation that could improve patient outcomes (Blair & Smith, 2012). Another research by Barker and Phillips (2010) relates to “insufficient drug information and inadequate drug references.” A new study on medication errors was conducted in San Diego, in

Your initial post clearly reflects the frustration that many nurses who give patient care a priority over the electronic documentation have in their minds. I do agree that at times documenting diagnosis, or the nursing interventions seem pointless but there is lots of benefits in using Standardized Nursing Language (SNL). Preventive measures for aspiration precautions, fall prevention, and prevention of skin breakdown are the ideal examples where nursing interventions make a significant difference in patient outcomes. In my facility, I see nurses being very particular in executing the interventions that are listed to make sure their actions meet the standardized documentation. Nurses in my unit are

“Computer system facilitate data collection but may increase the potential for entry of incorrect data through input errors” (Hebda, 2013, p.63). Countless errors can be influent the data accuracy and threaten the patient’s safety. Thus, organizations are implementing several measures to decrease the errors and ensure the high quality of data. Therefore, the most important two strategies that are utilized to ensure the accuracy and safety of data entered into information systems used in nursing practice are the education of personal and system checks. All employees must be educated, and education must emphasize the importance of data accuracy, potentially harmful effects of incorrect data and error corrections. The personal must be proficient with information technology and ensure that data content is accurate, complete, and concise. Furthermore, the staff must be competent in appropriate documentation guidelines and standards and practice universal language that is recognizable by all providers. Furthermore, the