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Documentation and reporting fundamentals of nursing
Documentation and reporting fundamentals of nursing
Importance of documentation in nursing
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The Need for Classification of Nursing Data in EHRs In the healthcare industry, nursing is underrepresented in the development of healthcare policies. Current nursing practice depend on the use of standardized nursing terminology and documentation to accurately communicate identified nursing diagnoses, nursing care provided, and interventions that were performed within healthcare disciplines. The essential solution to making nursing more visible, having necessary data to adequately measure the direct effects, and retrieve associated costs of nursing care is to attach nursing care services with each patient. Minimum data sets for nursing are vital classification systems necessary to categorize the practice of nursing. Minimum data sets allow …show more content…
The NMDS data is used to define, communicate, and compare nursing practice. NMDS portrays a comprehensive depiction of the patient’s encounter, patient problems, identify nursing diagnoses, determine nursing interventions or nursing actions that were completed, assess nurse-sensitive patient outcomes, and examine nursing resources utilized in the provision of nursing care. Through the connections between nursing and other professional systems, nurses can access specific data, as well as distribute data to other health care providers and researchers (Mennella & Caple, …show more content…
The solution to making nursing discernible and having required data to adequately measure the direct effects and related costs of nursing care is to link individual care with each patient through standardized nursing terminology systems, NMDS and NMMDS. As a nursing manager in a hospital, it is important that the healthcare system adhere to reform reimbursement to lessen additional costs associated with hospital-acquired adverse events such as falls and/or pressure ulcers. The data is utilized to gain a perspective of care and its influence on the results of patients and staff. It categorizes common essentials to represent the delivery or perspective of nursing care at the unit level in any setting. These components can be measured to display the nursing constituent alone or as a segment of wide care outcomes (Coleman et al.,
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...
Young, W. B., Minnick, A. F., & Marcantonio, R. (1996). How wide is the gap in defining quality care?: Comparison of patient and nurse perceptions of important aspects of patient care. The Journal of Nursing Administration, 26(5), 15-20.
Hebda, T. & Czar, P. (2013). Handbook of Informatics for Nurses & Healthcare Professionals. (5th Edition). Upper Saddle River. : N.J: Pearson Education
... middle of paper ... ... Works Cited 1. Cooper, Paul, RN, MSN, Director of Nursing Informatics.
Many new technologies are being used in health organizations across the nations, which are being utilized to help improve the quality of health care. Electronic Health Records (EHRs) play a critical role in improving access, quality and efficiency of healthcare ("Electronic health records," 2014). In order to assist in expanding the use of EHR’s, in 2011 The Centers for Medicaid and Medicare Services (CMS), instituted a EHR incentive program called the Meaningful use Program. This program was instituted to encourage and expand the use of the HER, by providing health professional and health organizations yearly incentive payments when they demonstrate meaningful use of the EHR ("Medicare and medicaid," 2014). The Meaningful use program will be explored including its’ implications for nurses, nursing, national policy, how the population health data relates to Meaningful use data collection in various stages and finally recommendations for beneficial improvement for patient outcomes and population health and more.
Case Management Case management has become the standard method of managing health care delivery systems today. In recent decades, case management has become widespread throughout healthcare areas, professionals, and models in the United States. It has been extended to a wide range of clients (Park & Huber, 2009). The primary goal of case management is to deliver quality care to patients in the most cost effective approach by managing human and material resources. The focus of this paper is on the concept of case management and how it developed historically, the definition of case management, the components of case management, and how it relates to other nursing care delivery models.
K. Lynn Wieck, RN, PhD, FAAN, is the Jacqueline M. Braithwaite Professor, College of Nursing, The University of Texas at Tyler, Tyler, TX, and CEO, Management Solutions for Healthcare, Houston, TX; Jean Dois, RN, PhD, NEA-BC, FACHE, is the System Director for Quality and Nursing, CHRISTUS Health System, Houston, TX; and Peggy Landrum, RN, PhD, is Clinical Professor, College of Nursing, Texas Woman 's University, Houston,
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...
In the late 1960s, the first computer systems were installed in hospitals (Murphy,2010). The computer systems started in the basements of hospitals and now are in every nursing unit. Nursing informatics allows for a more efficient and faster delivery of health care. Nursing informatics is a way of keeping patient information properly organized and creating patient care plans.
Nurses across the globe are saving multiple lives daily. They work hard to take care of various patients with an array of different health problems. They are accountable for not only caring for the patient’s health but also being empathetic and friendly with all visitors. Exactly how many patients is a nurse responsible for keeping safe, comfortable, and alive? It is difficult to say because the nurse to patient ratio policies varies immensely across state borders.
Taylor, C. R., Lillis, C., LeMone, P., & Lynn, P., (2011). Fundamentals of nursing: The art and science of nursing care (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins
According to the American Nurses Association, nursing is defined as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations” (American Nurses Association, 2016). Nurses have many jobs and responsibilities and wear many different hats. Nurses can perform at many different levels depending on their scope of practice which is defined by the board of nursing in one’s state of residence. It is important as nurses to understand and follow
The nursing process is one of the most fundamental yet crucial aspects of the nursing profession. It guides patient care in a manner that creates an effective, safe, and health promoting process. The purpose and focus of this assessment paper is to detail the core aspects of the nursing process and creating nursing diagnoses for patients in a formal paper. The nursing process allows nurses to identify a patient’s health status, their current health problems, and also identify any potential health risks the patient may have. The nursing process is a broad assessment tool that can be applied to every patient but results in an individualized care plan tailored to the most important needs of the patient. The nurse can then implement this outcome oriented care plan and then evaluate and modify it to fit the patient’s progress (Taylor, C. R., Lillis, C., LeMone, P., & Lynn, P., 2011). The nursing process prioritizes care, creates safety checks so that essential assessments are not missing, and creates an organized routine, allowing nurses to be both efficient and responsible.
The profession of nursing is always regarded as complex, dynamic and noble. The nursing profession requires many things such as hard work, vast knowledge, excellent communication skills, and a passion for the noble profession. All these qualities are needed to be an effective nurse. Today, nurses are living in a world of ever changing field of medicine. The present patient statistics pose, nurses are expected to take responsibility of accomplishing the requirements.
Potter, P. A., & Perry, A. G. (2009). Fundamentals of nursing (Seventh ed.). St. Louis, Mo.: Mosby Elsevier.