Electronic Nursing Documentation and Patient Safety Nursing Documentation refers to any written or electronically produced information about a client that depicts the care or service rendered to that client. It is a requirement of The College of Registered Nurses of British Columbia’s (CRNBC) Professional Standards for nurses to record in details timely and exact reports of relevant observations, including conclusions deduced from those observances…
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A currently happening intensely serious and dangerous nursing shortfall can be meliorated in a number of ways. One method of them is to reduce or extinguish work life dissatisfactory for nurses of which one is the current cumbrous type of nursing documentation of patient care. According to routine or established practice, nurses spend approx 15 to 25% of their working day in documenting patient care, and in some cases this ratio is substantially more than that. This is not an problem as such, but perceptions by nurses that much of this documentation is unneeded or superfluous and above all that it takes away from their ability to deal with direct patient care, have made it a substantial matter for practicing nurses and issues about nursing documentation of patient care important to nurses and consequently to everyone. A recent and popular trend in nursing practice is the institution of electronic documentation. Uptil now, not much is known about this crucial trend or its effects on nursing documentation subjects (Gugert et al 2007). This purpose of this paper is to illustrate the importance of electronic nursing documentation and the standards developed for them. The majority of healthcare agencies have anticipated implementing some type of electronic health records (EHR) and electronic documentation systems. A model with standards to be used in various EHR demonstration projects has been suggested. Up to now, the EHR model has had many important consequences or implications on the entire healthcare community, ranging from huge enterprises to private practices, with many states forming planning board to formulate or develop strategies regarding how EHRs can be implemented comprehensively. The Health Information and Management Systems Society has formulated a definitional model that details eight properties and crucial requirements for an EHR, from the need for insure records that can be got at in real time to records that can facilitate and support clinical tests. All healthcare facilities are anticipated to have EHRs in place in the almost future to assure safety and improved documentation of care. For many reasons, the switch to a paper less healthcare record is an intimidating and costly venture for healthcare agencies, and not everybody is keen to the use of EHRs. Hence, acceptance rates have deviated widely from region to region. Many of the troubles discovered in implementation of EHRs are both behavioral and organizational, and may be assigned to attitudes towards the consumption of electronic technology or failure of the implementers to look for stimulus from potential users (Moody et al 2004). Electronic documentation and health records are believed to better the quality of care and service rendered to hospitalized patients. The use of electronic documentation sources has become extremely relevant for nurses as they can find the majority of essential patient information thereby. Currently the majority of U.S.
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