Nursing documentation is defined as the record of nursing care that is planned and given to individual patients and clients by qualified nurses. Nursing documentation is essential for good clinical communication (Blair & Smith, 2012). An appropriate, legible note provides an accurate refection of nursing assessment. Quality nursing documentation promotes effective communication between caregivers, which facilitates continuity and individuality of care (Koutoukidis, Stainton, Hughson & Tabbner, 2013). In addition, nursing documentation can be used for other purposes such as quality assurance, legal purposes, health planning, allocation of resources and nursing development and research. For achieving these purposes, nursing documentation needs to hold valid and reliable information and comply with established …show more content…
In this paper, I will reflect on the documentation assessment did the lab. I will reflect on my experience on progress notes written in the lab.
There was an assessment in the lab class in which we have to write progress notes of a patient. Firstly, in the lab class: I wrote progress notes too long. Then, my assessor corrected me and explained that notes should be clear and concise with important and up to date information of the patient. Then, for the second time, I tried to write comprehensive, clear and concise progress notes. It was much better than the previous one but still needs a sequence in writing. I felt very bad because every time I tried, still there were mistakes. Writing notes always put me in a situation where I need to think to find exact words and sequence to express what happened with the patient. I think; I need more consistency in writing
The adoption of clinical information systems is one way that healthcare organizations are making an effort to improve patient safety, provide a means to exemplify regulatory compliance, and facilitate exchange of patient information between care providers (Kirkley & Stein, 2004; Nadzam, 2009). To achieve this goal, Barnes-Jewish Hospital (BJH) recently implemented a new CPOE/clinical documentation system. One of the objectives of the new system was to give bedside clinicians a standardized electronic tool, known as the Clinical Summary, for bedside shift hand-off reporting. Soon after go-live, it was identified that the standard nursing Clinical Summary did not meet specialized the reporting needs of the nurses on the Women and Infants divisions. Consequently, an application enhancement request was submitted. The goal of this project is to synthesize the knowledge gained throughout this Masters Degree program to initiate, plan, and execute changes to the current clinical documentation system to provide a standardized Clinical Summary review screen to meet the specialized hand-off reporting needs of the nurses on the Women and Infants divisions at BJH. This paper includes project objectives, a supporting evidence-based literature review, project methodology, formative and summative evaluation criteria, and a graphical timeline with a narrative description for the Women and Infants Clinical Summary project.
On a daily basis, I will have to engage in charting and documentation writing to ensure patients receive the best possible care. Charting will involve patient identification, legal forms, observation, and progress notes. Documentation must be factual with objective information about the patients’ behaviors. Accuracy and conciseness are crucial characteristics of documentation in the nursing profession so that other medical professionals can quickly read over the information (Sacramento State,
Licensed practical nurses (LPN 's) fill an important role in modern health care practices. Their primary job duty is to provide routine care, observe patients’ health, assist doctors and registered nurses, and communicate instructions to patients regarding medication, home-based care, and preventative lifestyle changes (Hill). A Licensed Practical Nurse has various of roles that they have to manage on a day to day basis, such as being an advocate for their patients, an educator, being a counselor, a consultant, researcher, collaborator, and even a manager depending on what kind of work exactly that you do and where. It is the nursing process and critical thinking that separate the LPN from the unlicensed assistive personnel. Judgments are based
There are many documents that will be used as a pediatric nurse such as growth charts, percentile charts, patient charts, physician notes, follow up letters, and infant basic care information packets. All the documents no matter how small they may seem are an important part of the patients
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...
Nursing and Midwifery Council (2008) The Code Guidelines for records and record keeping. London: Nursing and midwifery council
“The ultimate value of life depends upon awareness and the power of contemplation rather than upon mere survival” (Aristotle, n.d.)
The following essay is a reflective paper on an event that I encountered as a student nurse during my first clinical placement in my first year of study. The event took place in a long term facility. This reflection is about the patient whom I will call Mrs. D. to protect her confidentiality. Throughout this essay I will be using LEARN model of reflection. I have decided to reflect on the event described in this essay since I believe that it highlights the need for nurses to have effective vital signs ‘assessment skills especially when treating older patients with complex medical diagnoses.
Dougherty, L. & Lister, s. (2006) ‘The Royal Marsden Hospital manual of Clinical Nursing Procedures: Communication 6th Edition Oxford: Blackwell Publishing Ltd
What is the central component of advanced practice nurses (APNs) direct clinical practice and patient/families?
A study conducted by academics found that undergraduate nurses feel reflection is the key to changing and improving their practice. (Bulman, Lathlean, & Gobbi, 2011). Reflection assists nurses to enhance their nursing abilities by encouraging them to reflect on negative experiences, in order to overcome similar experiences in the future. This essay will aim to demonstrate the importance of reflection within nursing, additionally providing me with a platform to reflect on my decision to become a nurse. I will begin by reflecting upon the factors that influenced me to choose nursing, followed by an explanation of the benefits that reflection has on nursing. The essay will conclude by summarising how I will put reflection in practice throughout
Saying that you are a registered nurse is a broad statement. Registered nursing is a job that has many aspects. Registered nurses work in many different settings and they carry out many different routines. As a registered nurse you could be exposed to many different opportunities. My goal is to be a registered nurse but, I need to learn a lot. Becoming a being a registered nurse requires a lot of hard work and effort but, if I focus on my goal I will be able to achieve it.
There should be experienced staff and adequate staff on night duty. Inexperienced trained staff trained with additional training. While caring the patient the nurses should always think about the religious background of the patient and should provide care accordingly. The nurses should always respect the dignity of the patient and should always follow the moral and ethical values of the patient. Documents is the only legal proof that protect the nurses from legal issues. So, nurses should be careful while documenting the patient condition. The document should always be complete and clear. The document provides other staff a clear view regarding what was carried out before and in the future it provides the pathway for designing the treatment modalities for the patient. document could be in any form written or computerized. The documentation error should be minimizing to maintain the quality of service. Negligence is one of the major problem in nursing field. Nurses neglect the important thing due to which there are more probability of having legal sue as well. The negligence of the nurses may risk the life of the patient. Therefore, should always prevent legal and professional issue. All hospitals and health care team member should always observe for the illegal activities of nurses. It is very important to report if something illegal and unprofessionalism is seen in the work and nurses’ attitude. Due to the negligence of the nurses the patient might have died. To prevent this the education should be provided to the patient regarding the legal and professional issues. This is because, the nurses have minimal knowledge on legal and professional issues. It is very important to upgrade their knowledge and participation of nurses in decision making is important so that they would think critically
The interdisciplinary course is a core requirement in the after-degree nursing program as it incorporates the principles of self-directed learning and promotes critical thinking, which is an essential element in nursing practice. As a final year nursing student, I believe that knowledge from this course will enhance my ability to provide patient-centered care.
In conclusion, developing academic writing is essential in nursing. Maintaining good quality of academic records and documentations will have an important benefit for the staff. It can benefit them from good communication, continuity, consistency and efficiency. Without academic writing nurses and other professions will suffer from lack of communication, errors in notes and documentation. Therefore, nurses learning how to write in academic form has a positive effect to the present and the future.