why is documentation important nursing

Accurate record-keeping is a vital part of good communication in nursing and integral to safe and effective practice. (1998) Discharge Planning for the Elderly: A Guide for Nurses. When a nurse is busy with a busy working day and many urgent demands on her time, keeping nursing records may seem like a distraction from the actual work of nursing: looking after your patients. According to Johnson, B. One innovation which supports this is that described by the NHS (2007) in The Essence of Care, which was launched in February 2001, as providing a toolkit to help practitioners to implement a structured approach to sharing and comparing practice, through principles of clinical governance, enabling them to identify the best and to develop action plans to remedy poor practice. 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Nursing Times. 12 0 obj The nurse engaging in discharge planning also needs to take into account the needs and capabilities of carers (Qualey, 1997). If care was provided that wasnt documented in a timely manner, the failure to document the care could put a patient at risk for getting a double dose of a medication(s), unnecessary treatments, or a discontinuity in medical care. Is the entry in the correct patients chart? According to a MGMA Consultant, nurses are responsible for almost 75% of chart use while physicians account for the remaining 25%. xc``$WR~|@T#2S/`M. <> The NMC code of conduct states that nurses should act to identify and minimise risk to the patient or client (NMC, 2004), and this applies to the action taken in the current situation and the potential protection of all clients in the future, in the avoidance of future errors of a similar nature. When you assume care for a patient, you are in essence saying that you will provide the patient with a standard of nursing care. There are Eleven Golden Rules of Documentation. Specifically in nursing, documentation helps to establish continuity of a patients care, justify clinical reimbursement, safeguard providers from malpractice, and foster communication amongst rotating providers. Williams, S.A. (1997) The relationship of patients perceptions of holistic nurse caring to satisfaction with nursing care. Why Is Documentation Important in Nursing? And once a nurse has administered a drug, they must monitor the patient for signs and symptoms of drug toxicity or other adverse reactions, and these monitoring activities must be fully documented, including any actions taken on notable findings and the patients response to these interventions (Austin, 2006). Solatatech is a website that writes about many topics of interest to you, it's a blog that shares knowledge and insights useful to everyone in many fields. This was the take-home message of a presentation by Joann Wortham, MSN, JD, CPHQ, CPPS, CPHRM, of Beta Healthcare Group in Alamo, CA, a large provider of professional liability insurance for hospitals, and Cyndi Maag, RN, BA, LNCC, of Eckenrode-Maupin, a legal practice in St. Louis, MO, during a session on Saturday, April 13, 2019, at the. Overall, incomplete documentation and delinquent medical records cause inaccurate reimbursement and results in inaccurate gross revenue to the hospital. There is also less care correlated to inaccurate or deficiency of information because the report process includes actual patient apparition. Effective discharge planning is also a vital link for continuity of care (Bull and Roberts, 2001), and so the failure of this process will lead to negative impact for the patient and their carers. Whatever the difficulties of the documentation processes concerned here, the documentation should have been complete and correct. Anyone on the nursing team who provides patient care can contribute to record keeping. the quality of care, the standards of regulatory agencies and nursing practice, the reimbursement structure in the health care system, and legal guidelines make documentation and reporting an extremely important nursing responsibility. Please refer to an authoritative source if you require up-to-date information on any health or medical issue. Each medical facility has a set of rules and standards to follow and it is important that each and every staff member takes the time to memorize and become accustomed to these codes because someones life could be at. Record keeping, Alternatively, you can purchase access to this article for the next seven days. It also allows the direction and planning of care. endobj It records care, demonstrating and communicating what procedures were carried out, when, and why. Sollins, H. (2007) Handling difficult family situations: practical approaches. This might ameliorate relationships between the acute and community sectors (McKenna and Keeney, 2000), and may prevent these errors occurring in the future. Accurate documentation is essential to maintain continuity and inform health professionals of ongoing care and treatment. Your guide to writing clear, concise records plus tips for effective handovers, Long-awaited plan for NHS in England needs more detail on how it will be delivered, Survey finds two-thirds of nursing students have considered leaving course due to finances, New option prepares students for community roles straight after qualifying, Making ends meet is about to get tougher for nursing students, Nurses share how individual patients care experience galvanised them to take action, With further industrial action off the table in England, we consider the implications, Find out how to prevent, identify and treat cellulitis to avoid severe complications, Nursing Standard is published by RCNi, the publishing company of the Royal College of Nursing. Period. Because lawsuits can take years to emerge, nurses should not take a chance by relying on their memory of events. Sure you can study the dusty textbooks, but they dont give you a pass guarantee. Thus, such a form should also be completed for the percieved drug error. endobj In this instance, the incomplete discharge documentation demonstrates that the required nursing care did not take place (as there is no evidence of it in the records). Related factors that influenced documentation comprised: limited nurses competence, motivation and confidence; ineffective nursing procedures; and inadequate nursing audit, supervision and staff development functions (Cheevakasemsook et al, 2006). Good documentation is important to protect you the provider. Therefore, it is essential for a nurse to review any relevant medical histories or clinical data regarding the client before an assessment and by talking to other caregivers information can be collected as a result of any arising or concerning, Over the intercom you hear Code Blue, 2nd floor, room 117. You hear doctors pagers ringing and see a herd of staff rushing into a patients room. Ting-Ting Lee, T-T. (2006) Nurses perceptions of their documentation experiences in a computerized nursing care planning system. In Norwegian nursing homes, undergraduate nurses are given major responsibilities in both planning and implementing nutritional care, and for that reason were invited to participate. No plagiarism, guaranteed! Journal of Advanced Nursing 39 (5) 450-458. The main point is Documentation protects nurses as well as patients, so make sure theres an easy way to keep track. He said that it is a prerequisite for quality care to facilities efficient communication and cooperation among health professionals as well as effective coordination. 1 HITECH includes incentives that provide reimbursements to hospitals and healthcare provider practices for adopting certified EHR technology an. Preparing for your CNA exam? That is why it is necessary to keep track of all the information you gathered about a patient, the medication they are taking, etc. Copyright 2023 IPL.org All rights reserved. The hospital is a hectic place with many on-edge people. Nursing Adviser, RN | MHS, Governors State University, IL Full member of the American Nurses Association. Also, catch this blog from our Director of Nursing for more nursing documentation best practices https://lnkd.in . Having the skills to articulate efficiently exists beyond having verbal skills. Effective record-keeping also promotes consistency while ensuring professional standards are . Nursing 2006 36 (1) 56-65. Activities and care: ambulation, turning and positioning, range of motion, catheter care, unsterile bandage changes, hot or cold compresses, bathing, etc. One such device would be an electronic health records system (EHR). We serve clinics, hospitals, community health centers, and individual healthcare practitioners across the US. Failing to chart care properly may have two dangerous consequences. (1997) Assessing the patients caregiver. In an ideal world and scenario nurses have the perfect amount staff with all the proper equipment readily available. 21 (1) 43-48. Documentation is a fundamental component of nursing activities such as assessment and care planning, according to the various models which have been designed for these functions (Nazarko, 2007). Despite the evident importance of nursing documentation, time spent on documentation can be substantial and therefore it can be experienced as onerous for nurses. It is understandable that the relative should be distressed and should be dealt with sensitively and apologetically. The focus of this analysis of the scenario is on documentation and the nurse. Purpose of the medical record Accessed 10-5-07. This also underlines the need to ensure the highest possible standards of care are both implemented and fully documented throughout every stage and componenet of nursing practice. For example, you might choose to always use a head-to-toe method. The medical record is the most important piece of evidence in a malpractice lawsuit, Wortham said, forming the basis for both allegations and defense. Background: Although access to accurate patient documentation is recognized as a prerequisite for delivering of safe and continuous municipal elderly care, healthcare professionals often fail to provide comprehensive clinical information in an accurate and timely manner. [/ICCBased 13 0 R] One of the first and most important principles taught in Nursing School is this: "If you didn't document it, you didn't do it." A blended learning degree could be for you. It is also imperative that nurses value the social aspects of patient care and that this is seen as an integral part of the discharge process (Atwal, 2001). Here you can choose which regional hub you wish to view, providing you with the most relevant information we have for your specific region. Therefore, any work done to address this error must examine where communication processes failed, and the documentation here should provide the evidence of where this failure occurred. In this essay will discuss about the importance of documentation, the factors that affect documentation, common errors in documentation and the ways to improve documentation for nurses. The importance of proper documentation may also be because it serves multiple and diverse purposes for nurses, for patients, and for the health profession, because current health-care systems require that documentation ensures continuity of care, furnishes legal evidence of the process of care and promotes and facilitates the evaluation of the q. Patient whiteboards were upgraded and are use to the fullest, they serve as a communication tool between hospital providers and as a mechanism to engage patients in their care, whiteboard use could improve teamwork communication as well as patient care and awareness of their care team, admission plans and duration of admission, and significantly improve patient overall satisfaction. Hyde et al (2005) highlight the limitations of the forms of documentation (and the forms of communciation which characterise that documentation) within nursing practice. Just think every time you go into the doctors office or have an overnight stay in the hospital what all to do your nurse during their shift? Because once its entered in the chart, no one will doubt that the care has been given and give it again. Accurate, relevant, and consistent. He said that it is a prerequisite for quality care to facilities efficient communication and cooperation among health professionals as well as effective coordination. Without advertising income, we can't keep making this site awesome for you. As another example, its fine to chart that a patient is complaining of severe pain or saying that his or her level of pain is 9 out of 10, but not that the patient has a low tolerance for pain or that he or she is childish. According to experts, avoiding these common mistakes while compiling medical charts can help nurses minimize documentation-related legal concerns: In addition to this, nurses should also take care not to use any derogatory language when writing notes about patients or colleagues. Take Charge of Your Nursing Career How does having proper records help your patients? Nursing is a profession that requires the ability to care for patients and documents and communicate their treatments. Perhaps developing better charts and records, in liaison with all staff, might also ameliorate the situation. Professional autonomy on the part of nurses demands a degree of mature clinical and ethical judgement in emergent and complex situations, and it is the documentation, if correctly completed, which should also signpost this process of judgement and decision making. The NMC code of conduct also states that all nurses are accountable for their own practice, and must account for their own acts or omissions (NMC, 2004). 333-6. From the legal perspective, Nursing Times states that the documentation should demonstrate: Nursing records that are incomplete, inaccurate, untimely, illegible or inaccessible, or that are false or ambiguous can obstruct legal fact finding, endanger the legal rights, claims, and defenses of both patients and health care providers, and increase risk of liability of the healthcare organization and providers. However, one of the problems with nursing documentation, as found in some empirical nursing studies, is that the complexity of nursing documentation does not always allow it to serve its many functions (Cheevakasemsook et al, 2006). Therefore, those working in a medical facility must understand the codes and procedures used by the facility; this is an example of a discourse community. You need someone in your corner telling you what your managers really need from you, helping you learn to interact with your preceptor, and really just manage your life. Journal of Advanced Nursing. Of these, this scenario shows occurrences of incomplete documentation, whereby the documentation related to discharge planning has not been completed. Recordkeeping allows physicians to communicate more effectively with other healthcare providers and staff within a hospital setting; it improves the overall quality of care delivered at hospitals, minimizes risk through accurate Documentation, facilitates continuity of care among healthcare personnel. Example, According to Julia Wood (2004), communication is a systemic process in which individuals interact with and through symbols to create and interpret meanings. Here are some good tips to follow when charting: Do's . It is a process that allows patients to make a well-considered decision about their care. Documentation is not difficult, but it must be done properly. One of the most critical responsibilities of all health care professionals is producing proper documentation. Study for free with our range of university lectures! It also provides legal evidence. The point is underlined by the Nursing and Midwifery Council (NMC) code, which states that to practise safely, nurses must keep clear and accurate records relevant to their practice. It is almost impossible for them to remember everything they do and everything that happens during a shift. Therefore, if you do it, chart it! How does having proper records help your patients? If you report something about the patient to other team members, note that as well. Today, nurses also need to be technically savvy to work with electronic health records (EHRs). Proper documentation promotes safe patient care, good communication among staff members, and the advancement of the nursing profession. (2003) Prerequisites and consequences of nursing documentation in patient records as perceived by a group of Registered Nurses. Informed consent is much more than simply reviewing the possible side effects of treatment or obtaining permission and a signature, she said. Fundamentals Of Nursing For LPN / LVN / RPN: Chapter 7 - Documentation of Nursing Care | LPN Student, Letter of Intent: 5 Types And How To Write Them, Nestle Market Analysis and Marketing Strategy, Interview Questions About Co-Workers and Supervisors, The Consortium Quick Start Guide and FAQs, Supply Chain Management Jobs: High Paying Salaries & Benefits, Give users admin permissions | Atlassian Support, Managing service project notifications | Jira Service Management Data Center and Server 5.9, Managing access to your service project | Jira Service Management Data Center and Server 5.9, Setting up service project reports | Jira Service Management Data Center and Server 5.9, Get started with service requests in Jira Service Management. Avoid repetitive copying and pasting. <> The documented recordings do not only help to keep your patients healthy, but they even help you in getting an idea about how others care is going on with them, i.e., what changes have been happening since when. This essay may contain factual inaccuracies or out of date material. A critical incident reporting from should also be completed, according to Trust policy, in order to ensure that risk management are informed and actions can be taken to prevent such occurrences in the future. Similarly, the blood error could have had significant consequences, and should not have occurred, given the nature of the procedures involved, and the clear links between safety and existing documentation. Good documentation is an important part of improving both patient care and nursing practice. In a systematic review of research literature to test the hypothesis that care planning and record keeping in nursing practice has no measurable effect on patient outcomes, the authors were unable to identify any robust studies for review (Moloney and Maggs, 1999). Utilising alternative modes of documentation may also enhance practice and recording behaviours. The nurse plays a unique and pivotal role in discharge planning, as a key member of a multidisciplinary team (Fielo, 1998) role. Given the strong nature of this medication, their specific nature and mode of action which can be tailored to the individual disease following culture and sensitivity tests, and the need to ensure they are given at the correct intervals, particularly as some such drugs can become toxic in larger doses, the proper recording of their administration is a vital part of the administration process. Whilst it is often related to the legal importance of accurate record keeping, it is essential to remember that documentation is also a good way of communicating with your colleagues. Fill a whole card and lose grip with reality. In medical facilities, it is common to use codes as a means to announce a situation to the medical staff without alarming the patients or visitors. If not done correctly, this could be illegal and even prove detrimental instead of helpful. All medically releveant facts realted toan incident should be recorded in the medical records, according to the Trust and ward policies and protocols (Austin, 2006). Now it comes to the main point about how keeping documentation can help you. This way, it becomes much easier for you to work on preventive as well as curative measures. We will never spam you. The well-documented records can help you to identify the patterns of your patients health. If you need assistance with writing your essay, our professional essay writing service is here to help! endobj Therefore, legally, the nurse taking care of this patient will be liable for the errors that have occurred. If she does not, then it is my responsibility to act on these concerns myself. Another error which relates to documentation is the issue of the patient who was discharged inappropriately. Journal of Clinical Nursing14 594-600. Many nurses dread documentation because it takes them away from patient care but proper documentation can help nurses avoid medication errors and legal troubles. Nursing Management. It also helps in providing a clear picture of their mental status and physical condition. Qualey TL. Journal of Clinical Nursing 15 (11) 13761382. 2023 Combined Jewish Philanthropies of Greater Boston. In relation to the sphere of practice, as a D Grade Staff Nurse I have a senior nurse present on the ward, who will be in charge during the shift.
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