The Importance Of Charting Input And Output And How Accurate Measurement Influences Patient Outcomes Essay

Although EMR’s may be taking over the medical world, paper medical charts remain the most well recognized form for keeping medical records. There are however some things within paper charts that some medical personnel might argue make it a primitive aspect of the medical field. One argument in itself is that the abundance of paper that is utilized in paper charting doesn’t stand up to the “green” society we aspire to live in today. “Paper charting used to take so long, the papers would always get unorganized, they took up so much room in the nurses’ station and the worst was waiting for a doctor to finish with a chart so I could chart what I needed to” (Brittney Guggino LPN, 2012). Another acknowledged concern with paper medical charts is the illegible handwriting of clinicians, which is a common, longstanding problem. Being unable to read orders clearly creates an added risk when dealing with patients treatments, medications etc. Paper charts may be familiar but they come with many downfalls and it’s these downfalls which may sway a person’s decision in the opposite direction in regards to the

Double checking of medications with a senior nurse is a strategy that is used to improve patient safety by reducing medication errors. This is especially important for paediatric medication administration. It is important that staff members both do dosage calculations separately, as this is how errors are discovered before the medications are administered (Lan, Wang, Yu, Chen, Wu, & Tang,

541). Interventions should be rendered continuously, promptly and appropriately as it can cause life-threatening complications (Holt 2009, p. 26). Apparently, the patient is stable, but continuous assessment and management should be done to avoid recurrences of untoward signs andsymptoms and prevent potential complications. Firstly, continuous assessment and vital signs should be done and these include blood pressure, cardiac rate, respiration, venous distention and skin turgor to assess possible occurrence of fluid overload as a result of rapid administration of large fluid that is often needed to treat the patient with DKA (Smeltzer & Bare 2004 p. 1185). Aside from this, documentation of fluid intake and output should be monitored and documented to assess for circulatory overload and renal function (Holt 2009, p. 61). Significantly, it is integral in the provision of continuous care that nurses reassess the factors that may have contribute or led to DKA, and educate the patient and his family about strategies to prevent its recurrences (Smeltzer & Bare 2004 p. 1186; Lemone, Burke & Bauldoff 2011, p. 551).

The biggest concern the FBCH emergency department faces while using paper charting is the errors made due to sloppy hand writing, failure to document procedures in a timely manner, and miscommunicated orders. During an emergency situation, providers often rush when writing orders and most doctors have chicken scratch for handwriting as it is without the added pressure of being pressed for time. When nursing staff cannot read an order or misread an order it can cause the patient undo harm. One such case happened in the FBCH emergency room when a nurse at first

Hospitals regularly measure patient care, which is defined as any health care service provided to an individual. It is measured in different ways according to the type of health care service provided. However, there are basic principles that guide how all patient hospital care is measured.

Gathering observations of patients is a vital task that all Nurses must complete on a regular basis, they include Blood pressure, respiration rate, pulse, temperature and oxygen saturation. The information gathered from the observations enable for warnings when a patient is deteriorating

Hello Stephanie! Nurses work the closest to the patients and are continuelly developing and refining ways to bridge the gap between quality outcomes and patient safety. A significant portion of our documentation is recorded on the EHR and error reporting system and since we do know our patients so well this provides an excellent opportunity for the EHR system to monitor for consistent identification of patients who are at risk, a timely communications to other healthcare providers, better decision-making for the care delivery as well as data collection and reporting that all help in the preventing the occurrence of pressure

It is evident that patient safety is one of the most important principal in place as a nurse. To insure this there are many standards that are set in place that as a registered nurse need to be met, some including, professional responsibility and accountability, having knowledge based practice, ethical practice, service to the public and self-regulation (SRNA, 2014). “These standards and foundation competencies serve as the criteria against which all registered nurses, practising in all domains of nursing practice (direct care, education, administration, and research, and the evolving domain of policy) will be measured by clients, employers, colleagues and themselves”(SRNA, 2014). Having these standards allows register nurses and the public to have a clear understanding of what needs to be met in order to insure that there is proper patient safety. However there are still many issues that contribute to unacceptable patient safety, including medication administration errors, post operative care, and patients mental health. However, “medication errors are one of the most common types of medical errors that occur in healthcare institutions” (J.Choo, 2010). A medication error, according to The National Coordinating Council for Medication Error Reporting and Prevention “is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or

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

Progress. Over the last decade, the hospital has made a lot of progress regarding the use of HER’s. After the CPSI system was initiated, the transition from paper charts to computer charts began. Today, all charting is done electronically by all members of the healthcare team. From the dieticians to the physicians, everyone is trained and

As healthcare continues to develop, so too has the technology involved. In the article, “A Controlled Trial of Smart Infusion Pumps to Improve Medication Safety in Critically Ill Patients” the authors seek to understand the impact of smart pumps, how they are used in the clinical setting and how this technology effects medication errors and adverse drug events. The thesis of this article recognizes that while the medication administration process is complex and allows many opportunities for error, the impact of advancing technology has great promise in improving the safety of infusion-based medications. The study also provides an opportunity to understand how critical care nurses are (or are not) integrating new technology into their practice. This non-blinded, prospective time series study sheds light on the fact that both the technology and the nurse’s performance were the critical factors in the current rates of intravenous infusion errors (Rothschild et al., 2005, p. 13, 20).

It is also important to keep accurate record of Liam’s fluid balance chart, and assess Liam’s capillary refill, skin turgor, fontanel condition and mucous membranes every shift, as they provide information about the infant’s hydration status (Axton & Fugate 2009). Urine analysis may be performed to provide information on hydration status and/or determine if Liam has urine tract infection (UTI) (Axton & Fugate 2009; Crisp, Taylor, Douglas, & Rebeiro, 2013). Management of dehydration would be one of nursing interventions if urine sample shows a high urine specific gravity, and antibiotics would be administered if a bacterium is detected in the urine sample (Axton & Fugate 2009). Feeding ability should be assessed in order to determine the route of fluid intake (i.e. oral, nasogastric or intravenous fluids) (PMH, 2013).

When you look at how nursing documentation affects patient outcomes consider all the benefits of informatics. Electronic charting systems allows for automation in patient safety issues. This automation can be prompts that forces a nurse to address things like abuse history, and many other requirements from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and if the nurses document, there is a history of abuse, the system can automatically send a referral to a department to follow up on the nurses charting. The clinical systems store valuable information, and re-populates, this information on later admissions. An example of this valuable information, would be a patient with the diagnosis of methicillin-resistant staph

This is especially important on those patients admitted with low mortality risk DRGs. This is accomplished by identifying and preventing, potentially avoidable complications and adverse events. For example, patients admitted for syncope and collapse secondary to dehydration will more than likely be placed on IV Fluids. One goal would be to hydrate the patient and reevaluate them throughout their hospitalization for improvement. However, if the patient’s intake and output is not monitored closely, the patient can become volume overloaded and develop symptoms similar to those seen with Right Sided Heart Failure. Once that happens, the patient will require additional medications and additional hospital days because of provider error of not placing an order for the Nurses to monitor his/her volume status.

Similarly to doctors and pharmacists, nurses also rely on the metric system and are required to convert measurements quickly. Many nurses deal with this daily through calculating IV drip rates. Most IV bags contain one thousand cubic centimeters of fluid. A doctor may order his/her nurse to administer one thousand cubic centimeters every 8 hours. This may not seem too difficult, but in order to do this a nurse has to precisely calculate the drip rate of the machine so that the patient gets the required amount of medication in the time frame the doctor suggests. In contrast, a smaller bag of IV fluid may require instruction to give a patient five hundred milligrams every thirty minutes (Boyd). Before calculating the drip rate of the small bag, a nurse would have to convert the original cubic centimeters to milligrams.