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Background Nurses have long been known for their attention to patient care. The reason many nurses have entered this profession is due to their desire to care for people. The overwhelming responsibilities of documentation, chart reviews, verifying orders and medications, monitoring lab results, among others, leaves the direct care of the patient to another, possibly unqualified, staff member. Bolton, Gassert, and Cipriano (2008) estimate that a mere 23-30% of a nurse’s day is spent providing care to a patient. This leaves the greater part of a 12-hour shift performing some kind of paperwork. In fact, the inability to provide more patient care has been cited as a reason many nurses leave their job, and the profession altogether (Bolton et al., 2008). The task of documentation is vital to nursing practice. Many times, however, this documentation is repeated in different areas of a patient’s chart. DiPietro et al. (2008) reported that 40% of the written documentation done by nurses was on personal paper at the patient’s bedside. This had to be copied into the formal patient record at a later time, resulting in double documentation. The reason nurses are forced to use this method of documentation instead of transcribing assessments directly into the chart is that this vital record of the patient’s information is often not readily available. Because several disciplines of the healthcare team require the chart throughout the day, there is no guarantee as to when the nurse may actually have access to it. Additionally, in almost all hospitals that utilize paper charting, the chart must travel with the patient when he or she leaves the floor for testing or procedures. This creates another roadblock to all members of the healthcare tea... ... middle of paper ... ...ledge. Sudburry, MA: Jones and Bartlett. Joint Commission on Accreditation of Healthcare Organizations. (2002, August). Health care at the crossroads: Strategies for addressing the evolving nursing crisis. (White Paper). Washington, D. C. Ketchum, B. (2008). IT equals better patient care? Nursing Management, 39, 21. doi:10.1097/01.NUMA.0000320634.89059.9a Office for Civil Rights (2003, May). Summary of the HIPAA privacy rule: HIPAA compliance assistance. [Privacy Brief]. Retrieved from the Department of Health and Human Services website: http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/privacysummary.pdf Thede, L. Q. & Sewell, J. P. (2010). The informatics discipline. In L. Q. Thede & J. P. Sewell (Eds.). Informatics and nursing: Competencies and applications (3rd ed., pp. 313-316). Philadelphia, PA: Wolters-Kluwer/Lippincott, Williams, & Wilkins.
U.S. DHHS (2002). Understanding HIPAA Privacy and Security Rules. Retrieved January 20, 2011, from http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.
Hebda, T. & Czar, P. (2013). Handbook of Informatics for Nurses & Healthcare Professionals. (5th Edition). Upper Saddle River. : N.J: Pearson Education
... Health Information Privacy For Consumers. Retrieved April 22, 2009, from U. S. Department of Health and Human Services: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
... middle of paper ... ... Works Cited 1. Cooper, Paul, RN, MSN, Director of Nursing Informatics.
Nurses have a considerable amount of responsibility in any facility. They are responsible for administering medicines and treatments to there patient’s. While caring for there patients, nurses will make observations on patient’s health and then record there findings. As well as consulting with doctors and other healthcare professionals to plan proper individual patient care. They teach their patients how to manage their illnesses and explain to both the patient and the patients family how to continue treatment when returning home (Bureau of Labor Statistics, 2014-15). They also record p...
Summary of the HIPAA Privacy Rule, Office of Civil Rights Privacy Rule Summary, (2003). Retrieved November 12, 2011 from http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/privacysummary.pdf
McGonigle, D., Mastrian, K., G., (2012). Nursing Informatics and the Foundation of Knowledge (Custom ed., pp. 96-109). Burlington, MA: Jones & Bartlett Learning.
U.S. Department of Health and Human Services, Office for Civil Rights (2003). Summary of the hipaa privacy rule Washington, DC: Retrieved from http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/privacysummary.pdf
One way that effects patient care is when the interdisciplinary team has no access to the patients’ charts during that allotted time. In that case, the nurse reverts back to paper charting with flowsheets and checklists, until the system is back up and running. This can be very frustrating and difficult for the new nurses who haven’t ever worked with paper charting, but it is a challenge that can be easily conquered.
The authors consist of nurses, specifically: a Chief Nursing Officer, a Nursing Informatics Officer, and a Dean/Professor of Nursing at Belmont University. The article described how vital nursing documentation is to achieve optimal patient care, including improving patient outcomes & collaborating with other healthcare providers. Using Henderson’s 14 fundamental needs as a framework for their research, the authors proved a definition of basic nursing care and incorporated it into an electronic health record. The authors utilized a team of 16 direct care nurses who were knowledgeable with documenting ele...
Mastrian, K., & McGonigle, D. (2012). Nursing informatics and the foundation of knowledge (2nd edition). Burlington, MA: Jones & Bartlett
Thousands of nurses throughout the nation are exhausted and overwhelmed due to their heavy workload. The administrators do not staff the units properly; therefore, they give each nurse more patients to care for to compensate for the lack of staff. There are several reasons to why
Healthcare is constantly changing with the intention of improving patient care. The Institute of Medicine (IOM) issued a report introducing five core competencies for health professionals, in order to improve the Untied States healthcare system: provide patient-centered care, work in interdisciplinary teams, employ evidence-based practice, apply quality improvement, and utilize informatics (Institute of Medicine of the National Academies, 2003). IOM proposes that if all five core competencies are utilized by health professionals, quality patient care can be achieved. The facility in which this nurse work, is in need of improving their charting system. The facility currently utilizes two different software systems for charting, in addition to
The Future of Nursing Being a registered nurse affords one the option of working in many diverse healthcare settings. In any practice setting, the climate of health care change is evident. There are diverse entities involved in the implementation and recommendation of these practice changes. These are led by the Robert Wood Johnson Foundation (RWJF), the Institute of Medicine (IOM), nursing campaign for action initiatives, as well as individual state-based action coalitions. Nurses need to be prepared and cognizant of the transformations occurring in health care settings, as well as the plans that put them at the forefront of the future.
Informatics has integrated itself into the nursing practice daily. Sensmeier (2010) states, “Nursing informatics is known today as the "specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice." A main part of a nurse’s job is gathering data and turning it into information that all of the healthcare takers can use. For example, a nurse must take vital signs as part of their “data” and in turn put it into the computer system as information. This information is used to help care for the patient. Informatics impacts a nurse’s duties because of the technology utilized each day. The use of this technology developed transforms the nursing career because it improves patient safety, quality, and efficiency of care delivery (Sensmeier, 2010). Within the technology, nursing care is ultimately impro...