The importance of documentation may vary on different venues for as long the information is needed and for whatever purpose it may serve to different cases. They knew that there is a special tie between patients and nurses. This article highlights the advantages of accurate record keeping and the barriers to effective documentation in the community setting. Nursing documentation is essential for good clinical communication. Keywords: Nursing documentation, paper based documentation, electronic documentation Introduction Nursing documentation is considered as an important indicator to develop nursing care. Documentation that is accurate, timely, accessible and true reduces the potential for liability lawsuits and provides for better outcomes should a lawsuit advance. The nurses in the study confirmed the significance of documentation for patient care. DOI: 10.3912/OJIN.Vol13No01PPT05Key words: communication, North American Nursing Diagnosis Association (NANDA), Nursing Intervention Classification (NIC), Nursing Outcome Classification (NOC), nursing judgments, patient care, quality care, standardized nursing languageRecently a visit was made … If using handwritten documentation, entries must be legible. Preceding articles have provided an overview of the programme and discussed a range of staff development work programmes. Good documentation is: 1. This article describes work carried out on clinical documentation to promote delivery of the three quality ambitions of safe, effective and person-centred care. Their written accounts are critical for planning and evaluation of medical interventions and ongoing patient care. Documentation is the record of your nursing care. It plays an important role in monitoring and maintaining the standard of care given to the patient. In court, there are a lot of crimes or cases which is relevant and related to medical issues. Sloppy documentation practices can be used against a nurse in a malpractice lawsuit. Data privacy has become a major issue in most industries, and it is critical within healthcare. But keeping good records in nursing is much more than just "paperwork." Vol. Documentation is a powerful tool to be used in a nursing research or any case study. Proper and accurate documentation is essential to avoid types of nursing documentation errors, and for helping to avoid patient deaths or increased liability for the caregiving facility, physician, or nurse. Law courts adopt the attitude that if something is not recorded, it did not happen and, therefore, nurses have a professional and legal duty to keep records. of nursing documentation that should be met including completeness, clearing, and concision. Nursing Standard. Educator Resources|Education & Information Age Education News. Proper documentation from a legal perspective also protects patients' rights, such as in cases of sexual assault. The cost to the NHS of litigation rose from £2.3bn in 1998 to £4.4bn in 2001 (National Audit Office, 2002). In a legal sense, documentation and record keeping is also there for the protection of the nurse or healthcare professional. | What Are Internet Trolls? Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care. However, it's critical that nurses enter information that is accurate, valid and complete. Documentation is extremely essential in the nursing profession. In the field of nursing, proper and accurate documentation is critical. Accurate documentation is essential to maintain continuity and inform health professionals of ongoing care and treatment. Special Education – Autism & Related Disabilities, M.S.Ed. Essay writing service to help with your essay, Washington rehab information and resource, 5 most important things in careers research paper, Consider Studying Life Science Like Cody Moxam, Writer-Elite.com – professional custom writing service, Designed by Elegant Themes | Powered by WordPress. Other applications for nursing documentation include: Credentialing: Documentation allows for a performance assessment of healthcare practitioners as well as healthcare organizations as a whole. Regulatory: The goal in all of healthcare is to always improve the quality of care, patient outcomes and care delivery. One of the primary uses of documentation is communicating essential information to … Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice. Compliant with healthcare laws and facility standards T… All passed information and medical data can be studied again if there are any cases like epidemic, pandemic, or even to update the current morbidity and mortality rate of the entire population. Nursing documentation should reflect nurses’ critical thinking that leads to decisions or intervention in care. … Recording nurses should also date and timestamp their entries. Documentation is extremely essential in the nursing profession. How is it tied to nursing practice? b. A well-kept record can protect the practitioner in instances where the legal defence of their actions is required. Specifically in nursing, documentation helps to establish continuity of a patient’s care, justify clinical reimbursement, safeguard providers from malpractice, and foster communication amongst rotating providers. All nursing interventions listed in the notes are considered to be accurate and reliable. The importance of documentation Documentation, a critical way of determining the standard of care rendered to a patient to defend nursing action (nurse together,2010).This agrees with the ANMCs competency standard 1.1 where it states that 'Practices in accordance with legislation affecting nursing practice and health care'. Nursing documentation is important for both practical and legal reasons. Research: Documentation is at the very core of any research, medical or otherwise. Please contact us. If a specific action was not written in the documentation, this particular intervention is not valid even it was given by the nurse. Teacher Education – C&I – Teacher Leader, M.S.Ed. The nursing process requires assessment, diagnosis (nursing), planning, implementation, and evaluation. To find out more about the specific documentation standards where you practice, contact your state board of nursing.  A Tool for Nursing Research and Case Studies. Having an accurate record of a patient's medication also helps ensure that no negative interactions occur, particularly in the case of an emergency when patients may not be able to speak for themselves. Required fields are marked *. Well written care plans along with detailed progress or case notes both support and demonstrate quality care.. Keeping good records may seem like a burden, especially when nurses have so many care duties throughout their shifts. Michael Nuccitelli, Psy.D. Complete 4. Precise documentation is accurate, exact, and strictly defines the patient’s conditions. The document must be signed by the attorney-in-fact with his/her full name, address, marital status, and must be at legal age. This is especially important in cases where electronic systems might falter and manual documentation becomes necessary. Documentation is an integral part of performance data and analysis. Having protections built into documentation systems ensures that nurses can do their part in keeping data secure. For accurate aggregation and analysis of data, nurses should use standardized terms to describe every part of the care continuum —planning, delivery and evaluation of care. Expanding upon principle number two, nurses must receive training on the organization's documentation policies and procedures. Accurate 2. This is because it may be used as evidence to either incriminate or exonerate for nurses in case of … Internet Safety Notes & Quotes, Michael Nuccitelli, Psy.D. Lessons to be learned: This case points out the importance of documenting conversations with a patient who calls in with issues shortly after discharge. Documentation is a powerful tool to be used in a nursing research or any case study. Evaluation – this is where to determine if the goal of care met or still need additional actions to improve the care given to the patient. Documentation serves as the data from which to evaluate performance across organizations, from individual nurses to the entire health system. If documentation is incomplete, an organization may be unfairly deemed as substandard in its care outcomes. Considering the first theme, it reflected the importance of documentation. Teacher Education – C&I – Digital Teaching & Learning, M.S.Ed. ANA’s Principles for Nursing Documentation | The Uses of Nursing Documentation • 5 The Uses of Nursing Documentation Nurses document their work and outcomes for a number of reasons:the most important is for communicating within the health care team and providing information for other professionals, primarily for individuals All passed information and medical data can be studied again if there are any cases like epidemic, pandemic, or even to update the current morbidity and mortality rate of the entire population. If nurses are unaware of specific procedures, it can slow efficiency and impact patient outcomes. 1. – this is where to determine if the goal of care met or still need additional actions to improve the care given to the patient. In spite of numerous improvement efforts globally, inadequate documentation continues to be … Background: Documentation is an important function of professional nursing practise. Organized 6. Citation: Rutherford, M., (Jan. 31, 2008) \"Standardized Nursing Language: What Does It Mean for Nursing Practice? If evidence in these cases is improperly recorded by a forensic nurse, it could mean a perpetrator goes free. The importance of this topic has been realized here, in Jordan, and the Ministry of Health has recently started application of electronic documentation systems. This is where EMRs come in, and where effective EMR training of nursing students can play a … Your email address will not be published. An Interview with Manuel Varela and Ann F. Varela:  Hermann Joseph Muller—the Realm of Genetic Mutations, Arizona Legislature Calls for Immediate ‘Forensic Audit’ of Dominion Voting Machines. A characteristic of high-quality clinical documentation is documentation that is precise. MBA with a Specialization in Digital Marketing, MBA with a Specialization in Health Care Management, M.S.Ed. The nursing schools must be teaching the process of documentation as part of their curriculum from its basic procedures to advance. It is one of the important tools of studying nursing and to practice the profession effectively. Alternatively, holes in documentation contaminate a nurse's credibility, even if proper care was provided. 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). Nursing documentation is the record of nursing care that is planned and delivered to individual patients by qualified nurses or other caregivers under the direction of a qualified nurse [].Nursing documentation is the principal clinical information source to meet legal and professional requirements [].It is a vital component of safe, ethical and effective nursing practice whether done … Your email address will not be published. Factual 3. CheapWritingService.com – cheap essay writing service. Focus Charting. 29, 14, 44-51. Documentation serves as "evaluative evidence," guiding new mandates or care initiatives. By submitting this form, I am providing my digital signature agreeing that Youngstown State University (YSU) may email me or contact me regarding educational services by telephone and/or text message utilizing automated technology or a pre-recorded message at the telephone number(s) provided above. Nurses are on the front lines of patient care. a. Documentation establishing that the nurse had spoken with the patient's physician could have gone a long way in warding off allegations of negligence against the hospital and the nurse. But keeping good records in nursing is much more than just "paperwork." Nursing documentation is an essential component of professional practice to improve the quality of nursing care and should be accurate and complete [ 24, 25 ]. The NMC (2002c) states that doc… The atmosphere in healthcare environments can be frenzied. Nursing documentation can be either paper based or electronic based documentation. Timely (current) 5. RegisteredNursing.org: Medication Administration: NCLEX-RN, Nursing Times: The Importance of Good Record-Keeping for Nurses, ANA: Principles for Nursing Documentation, HealthIT.gov: Protecting Your Privacy & Security. This allows other care team members to accurately assess the patient's status and provide the type of care needed. Importance Of Nursing Documentation 1544 Words | 7 Pages. This determines which credentials or accreditations will be granted. Nursing Standard. Legal: The term "medical malpractice" is a healthcare provider's worst nightmare. The five phases of the nursing process to provide an excellent care to the patients are: Assessment – the process of investigating the objective and subjective aspect of the patient. With everything on a nurse's plate, completing documentation might seem less important than taking care of patients. A nurse can play a key role in research by meticulously recording patient characteristics and outcomes, which can then contribute to therapeutic developments. 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