The Importance Of Obtaining Quality And Safe Care

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.

The main objective of healthcare professionals is to provide the best quality of patient care and the highest level of patient safety. To achieve that objective, there are many organizations that help improve the quality of care. One of the best examples is the Joint Commission. Unfortunately, the healthcare system is not free from total risks. In healthcare activities, there are possible errors, mistakes, near miss and adverse events. All of those negative events are preventable. But, it is clear that errors caused in healthcare result in thousands of deaths in the United States.

Nursing documentation is important for continuity and quality of client care. It acts as legal evidence and provides evidence for quality assurance and future care (Porter & Perry, 2014). A SOAP note consists of Subjective, objective, assessment and a plan for the client care. This paper attempts to assess and document subjective and objective data for a case study involving a 46 years old male client brought to the urgent care with the complain of chest pain and identify three nursing diagnosis and provide a plan for each diagnosis identified.

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

This evidenced-base proposal paper is to address the lack of communication with the multidisciplinary team with home healthcare cases. This is a problem that is faced everyday by home healthcare nurses and other providers. Home healthcare is independent care provided at home these services can be provided over time and across geographic locations. Home care nurses tackle many responsibilities that include not only the patients but also family concerns and problems. Nurses are at the home front on a daily basis with individuals and need a decision/guidance support system to manage the different levels of care demands. One of the most important factors in maintaining continuity of care is the compliance with documentation. In order for providers to communicate with one another documentation needs to be clear and also requires a standardized nursing language (SNL) (Lee Eun, Lee, & Moorhead , 2009).

In the Veterans Centre (VC) at Sunnybrook Health Sciences Centre a standardized tool was developed to assist nurses with the completion of their pre-rounds documentation. However compliance with the tool on one patient care unit is falling below the nurse manager’s expectations. Additionally, communication of the notes’ information by nurses during rounds is not reflecting best practice and critical thinking. The purpose of this paper is to outline a proposal that will aim at improving these two aspects of professional nursing practice.

For this entry, I am going to reflect on the importance of how appropriate documentation can protect nurses if a lawsuit were to arise and how charting can help maintain standards of care and communicate the quality of care delivered.

J., Kharasch, M.S., Hongyan, D. (2010). Point of Care Documentation Impact on the Nurse-patient Interaction, Nursing Administration Quarterly, 34(1), 1-10

I think healthcare is a combination of both right and a privilege. I think that not everyone has good quality care, and sadly this is usually because to receive quality care you need to be able to afford it as well as be able to access quality care. I think that quality of care for the public is all ways evolving and getting better. The healthfield is always making advancements which results in better quality of healthcare. I do not think it is becoming more affordable health care, the cost of living and treatment is always going up as the pay decreases. The US is working on making health cre affordable, but still have a long ways to go. I lso think making healthcare accessible for more people through open clinics and how our world is expanding

According to Creasia and Friberg (2011), knowledge of appropriate documentation can protect nurses in the event of a lawsuit. Discuss some charting basics that can help nurses maintain standards of care and communicate the quality of care delivered.

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.

Mr Skurnick is respected as a subject expert in the application of perioperative standards of nursing practice. Because of his leadership abilities, he is sought out by the surgeons, anesthesia team, and colleagues to evaluate program and service activities. For example, he heads the auditing of nursing documentation pertinence. The data identified weaknesses in the OR nursing documentation, presents trending of missed opportunities, and created foundations for the improvement of patient care. He utilized this recognized body of evidence to support the NM to evaluate and develop an effective perioperative nursing development process. Beyond the application of this process on the perioperative units, through a review

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.

Documentation has been viewed as an important aspect of professional nursing practice since described by the founder of modern nursing - Florence Nightingale. This written record stands as legal evidence of accountability in the delivery of care, and serves as a method to communicate a patient’s status/progress between members of the interdisciplinary team (Chelagat, 2013). In the healthcare milieu, medical and disease focused charting is the usual practice among health care professionals. This biomedical-focused practice of documentation does not recognize the role of nursing practice in patient care as relational and holistic. A summary of a patients chart will be compared with a parallel chart developed with narrative ethics to facilitate discussion of this consideration.