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Importance Of Documentation In Nursing Information System

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DOCUMENTATION Documentation plays a very important part in the healthcare delivery system. It serves as a communication tool for all health care providers to ensure that there is continuous, safe, accurate, quality healthcare for each patient. Documentation also serves as protection for nurses, in case of any claim in regard to an alleged act of negligence or malpractice. When documenting nurses should always use factual, consistent, accurate, objective and subjective to ensure the patients progress and health care can be monitored. Nurses should always provide a rationale for any decision made. Jargons should be avoided when documenting to prevent any misunderstood communication. Can you imagine a paperless hospital? A hospital that doesn't …show more content…

The use of a nursing information system such as our Bar Code System, will document types of medications used in hospital settings catering to patient’s needs. It will also provide checks and double checks which is a valuable tool because it maintains the five rights of medication administration, notification are at the nurses finger tips, errors and warnings are readily available, allergy checking is automatically performed, dose checking and other relevant clinical data are …show more content…

Unfortunately proper assessment of a patient is not done due to the short staff of medical practitioners. What if I told you there is a way every patient can get a compassionate medical practitioner who would understand what is wrong with the patient and thoroughly explain what is happening, why it is happening and how to treat it all in the comfort of their home or somewhere convenient to them. This is very possible and it can be done by using Telehealth. Telehealth is using machine that can provide video conferencing with the doctor and patient. The machine is well designed and equip with high definition camera and audio that allows the medical practitioner to assess the patient. One might ask how a machine can allow an assessment via video conferencing. This is done because attached to the machine is an otoscope which is not like the traditional one, this otoscope has, installed in it high definition camera that can zoom in and other and capture clean digital pictures of the patient’s eyes or even the patient’s throat. Another equipment that is attached to the machine is a then stethoscope which provides the practitioner with audio of the lungs, heart, and

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Use the hospital or facility policy if there is a correction that needs to be made in the document. Do not scratch out, use liquid paper, or conceal any documentation. This makes the nurse look like you are falsifying

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As a nursing student I am taught how to document using special medical terminology, and the importance of documenting, however the article “Stay Out of Court with Proper Documentation” by Sally Austin confirms just how critical it is to be accurate, timely, and unbiased with patient documentation. Proper documentation not only helps keep the patient safe, but just as importantly protects the nurse should a lawsuit occur. Austin’s article defines the legal terms used in the more common lawsuit, negligence, involving nurses and how to avoid them. First, the patient must prove four things in order for a lawsuit to be deemed in their favor: A duty to the patient existed, a breach of duty occurred, the patient was injured, and lastly the injury

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(Hogue & Prudhomme, 2012) Another point is documentation on a patient. There is a saying in the medical field if you didn’t document it didn’t happen, make sure as a case manager, everything you do is fully documented in the patient record. Develop habits that are good, you always want to document on a client when everything is fresh. It proves to the case manager’s credibility.

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Specificity of diagnosis, abnormal lab test and medication is often vital healthcare information in the medical record. Failure to document this information significantly slows hospitals from collecting the correct level of payment. Hospitals should not only target coders for performance improvement given that no level of accurate coding can overcome the lack of documentation. The Doctors that underdocument care and services provided represent the most significant opportunity to increase charge and reflect the severity level and provide adequate defense. When researched, Advisory Boards nationwide has uncovered multiple cases in which improved physician documentation has increased annual by 1.5 million.

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Running head: LEGALITY AND ETHICS OF PATIENT DOCUMENTATION 1Legality and Ethics of Patient Documentation Matraca HillOzarks Technical Community College LEGALITY AND ETHICS OF PATIENT DOCUMENTATION2Legality and ethics of patient documentationNurses often hear the saying: “if it is not charted, then it was not done” from day one of nursing school. All states have what is called a Nurse Practice Act, which is governed by the state’s legislature and these laws protect the safety of nursing practice (Duclos-Miller,2016). By having this act it gives healthcare workers rules and regulation for their licenses and workplaces. Each state has a state board of nursing to make the laws effective and provide enforcement (Duclos-Miller,2016). Nurses must

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Documentation is evidence that the patient received proper care. This mean that, what is been documented is what had been done to the client, while what was not been documented indicate that were never been done to the client. Besides, the way of the documentation been written also play an important role. Documentation is a resources for others to assess whether the care that a patient received was met the professional standards for safe and effective nursing care, or otherwise. As well, various people whom read the report will have different kind of interpretations on what had been done.

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A considerable amount of healthcare professional communication is achieved through written forms and given the preventable nature of communication failure, understanding how healthcare professionals use document and documentation in their interconnected work is vital to improving patient safety (Braaf et al. 2015).Nurses have roles and responsibilities in direct care and therefore spend more time with patient than do other members of the healthcare team, there assessment and observations is thus crucial information that must be effectively communicated to their colleagues and other team members to enable them to make best-practice decisions ( Riley2017) , hence the significance of communication attribute in nursing. Nurses work in shifts or duty rotation due to the nature and urgency of services delivery in healthcare facilities. Besides, caring for the patients is a continuous process. Clinical handover takes place when a nurse on duty is transferring accountability, information, and responsibility for a single or set of patients.

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When the Hospital Standardization Program established their initial set of minimum standards, one of the prescriptive measures required healthcare organizations to maintain medical records for patient treatment. The necessity of creating, and preserving a detailed account of a patient’s history, laboratory results, and treatment seems rudimentary today. The Hospital Standardization Program made significant advances in enforcing proper documentation. Building on that legacy, TJC strengthened standards involving appropriate medical documentation by including strict timelines for completion. For example, TJC mandates a patient’s History and Physical (H&P) report be completed within 24 hours of admission.

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Azemobho Imaku Western Governors University Healthcare Compliance December 15th 2015 An inpatient coder is a professional, skilled at performing coding and abstracting of inpatient accounts using ICD-9-CM (International Classification of Diseases Ninth Revision, Clinical Modification) and CPT (Current Procedural Terminology) coding systems. An inpatient coder is also expected to be knowledgeable in medical terminology, disease processes and pharmacology. Some of the key responsibilities of the position include assigning codes for diagnoses, treatments and procedures, reviewing provider documentation to determine principal diagnosis, ensuring accurate coding, identifying non-payment conditions and ensuring medical record coding meets regulatory

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List the principles of documentation: Always document date and time Make sure handwriting is legible Use correct spelling Use only black or blue ink Use correct terminology include FACTUAL evidence Be accurate

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Using data can better nursing practice, improve patient safety and quality of care. There are several interventions based on research evidence that can be applied. The goal is to reduce medication administration errors. A reduction in medication errors would not be 100%, however, a goal approach of 75%, and then 90% would be a significant improvement over time. The design of the automated dispensing system (BCMA), would have a great impact on how nurses deliver their medications (Franklin et al., 2007, p. 282).

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o Food intake: Document the patient’s food and liquid intake. o Observation of the sick: Observe the patient, and document the observation. o Bed and bedding: Keep the bed comfortable, dry and wrinkle free.

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