Clinical Guidelines (Nursing) : Nursing documentation

Introduction
This is a topic essay paper for research practicum course which discuss about documentation. Documentation is an important part of the nursing process; it is a careful and accurate record keeping. It protects the client’s welfare; clients mean individual, families, groups, population who need nursing expertise. By documentation the nurse can communicate with other health professionals. It is needed to meet legal and professional standards.
The nursing documentation should include:
• Description of the assessment and care plan that is given to the client.
• The important information that is expressed by your client and your response to their needs.
• Any management that you provided to the client for the continuity of care.
• The understanding and fulfillment of your duty of care.

Conclusion
Documentation is an important process in nursing that should be taken in consideration. It is important to study any implementation in nursing documentation and the effect of this implementation on the nursing documentation process which is used for patient’s safety. Implementing computerized documentation and its effect on the quality of care that is provided for the clients will need to be studied. If this system will not provide any improve in care, why we have to use this technology. I know there will be some good things from using computerized systems for example it is not coasting a lot there will be no papers to be used, no manual files which will need a big space in the hospital to keep it in, and it is more secured and safe than the written documentation, but we should be sure that there will be an improve in the quality of care or at least the quality of care will remain same to the one with the written documentation. The quality of care has many concepts, to decide the concepts of the care quality I have to review the literature to know what are the quality concepts to study on and suitable the community that I want to make my study on.

Below is an essay on "Documentation For The Nursing Professional" from Anti Essays, your source for research papers, essays, and term paper examples.

Article 1 – “What is the JCAHO Standard of Documentation for Nurses in Emergency Departments?”

A vital element of healthcare information is nursing documentation. Information systems are designed for nurses where documentation can be best utilized to expand their knowledge of quality of care. The evolution of knowing has been exponential in the past forty years due to the new ways of learning that have been discovered. Nursing in particular has benefitted from these new concepts and continues to find newer and better methods to improve patient care. Nurses bring to their practice a personal history that develops the way their nursing care is performed. Nursing theory, standards of practice, legal and ethical obligations must be understood and utilized to enhance the quality of nursing care.

Nursing documentation is essential for ..

...Risk Management Nursing Documentation Oscar Chavez NUR 492 May 4, 2012 Susan Dean, RN, MSN, FNP Risk Management Nursing Documentation The issue of documentation of patient care has received considerable attention in the last few years for an array of reasons. Trends in society such as increased consumer education, informed consent, expectation for healthy baby, and an increasingly litigious society all contribute to increased risk management awareness on behalf of healthcare facilities. Risk management deals with the probability that a given risk will result in poor outcome and then attempts to reduce probability. El Centro Regional Medical Center (ECRMC) has identified nursing documentation as an area of greatest risk management. In this era of unprecedented change in healthcare, ECRMC has determined it was time to reengineer our existing approach to risk management consulting services to address more current needs for our patients and staff. The primary technique utilized in overcoming these limitations is to view training not as a stand-alone solution, rather as one element of a full performance improvement plan to address specific areas of concern. Instead of providing a general program on documentation, risk management has been working with nursing departments and other professionals to focus on the areas of deficiency or situations that need improvement. The foundation of risk management was broken into four separate issues. One was to pinpoint the exact...

A Topic Essay Paper on How Documentation is an Important Part of ..

...Risk Management Nursing Documentation Oscar Chavez NUR 492 May 4, 2012 Susan Dean, RN, MSN, FNP Risk Management Nursing Documentation The issue of documentation of patient care has received considerable attention in the last few years for an array of reasons. Trends in society such as increased consumer education, informed consent, expectation for healthy baby, and an increasingly litigious society all contribute to increased risk management awareness on behalf of healthcare facilities. Risk management deals with the probability that a given risk will result in poor outcome and then attempts to reduce probability. El Centro Regional Medical Center (ECRMC) has identified nursing documentation as an area of greatest risk management. In this era of unprecedented change in healthcare, ECRMC has determined it was time to reengineer our existing approach to risk management consulting services to address more current needs for our patients and staff. The primary technique utilized in overcoming these limitations is to view training not as a stand-alone solution, rather as one element of a full performance improvement plan to address specific areas of concern. Instead of providing a general program on documentation, risk management has been working with nursing departments and other professionals to focus on the areas of deficiency or situations that need improvement. The foundation of risk management was broken into four separate issues. One was to pinpoint the exact...

The author of this article provides justification for the use of a standardized nursing language, which will be necessary for incorporating electronic documentation into the health care field. The author defines standardized language in nursing, describes how such a language can be applied in a practice setting, and discusses the benefits of using a standardized language.

The following is an outline of an example response to the essay for Aged Care Nursing

Importance of Documentation in Nursing: The Do's …

This article considers best practice in record-keeping and documentation in the light of recent public inquiries and reports, renewed national interest in record-keeping standards, and the challenge of moving from paper to electronic healthcare documentation and digital storage of data. The nature of the nurse-patient relationship is also changing, and should be reflected in nurses’ record-keeping practices. Collaborative approaches to the planning and evaluation of care, and more emphasis on patients having a greater sense of ownership of information held about them should be reflected in nurses’ and other healthcare professionals’ attitudes and approaches to this aspect of practice.