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Critical Appraisal Assignment Name: Institution : Course: Tutor: Date: Introduction Documentation in the profession of nursing can be defined as the process of keeping timely, accurate and relevant medical records of patients that a nurse has handled (Lippincott Williams & Wilkins, 2007, p36; and Lippincott Williams & Wilkins, 2006, p48)…
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Download file to see previous pages In addition, the care giver also records the measures that he has taken in response to the patient’s needs, evidence that he has comprehended and pleased the responsibility of care, has taken all reasonable steps to care for the patient and that any action or exclusion has not put into compromise patient’s health. The documentation also includes a record of any arrangements the nurse has made for the continuing care of a patient or client (Delaune & Ladner, 2006, p68). The documentation process in nursing is carried out for various reasons that may include some of the following. The law in most of the countries requires that health practitioners who come into contact with patients should keep health records of the patients that they handle, these records are supposed to include a brief record of the patient’s medical history and the care that the health practitioner gives the patient (Guido, 2006, p72). In addition, the number of litigations against nurses has increased due to the increased public awareness of their rights therefore the documents act as evidence in courts of law of the care that the nurse gave the patient. Keeping of proper medical health records also has an implication on the quality and type of care that the patient will receive from other nurses since they are likely to dwell on the medical history of the patient written by other nurses who handled the patient. This report will critically analyse three journal articled relating to the field of documentation in nursing. Nursing Documentation: Frameworks and Barriers This paper written by Wendy Blair and Barbara Smith deals with barriers to safe, timely and accurate documentation for nurses and chooses the best framework to handle the problem of documentation (Blair & Smith, 2012, p65). This article involved studying of various literature on frameworks that ensure documentation in nursing fulfil the requirement that it should show the rational and critical thinking behind clinical decisions and interventions while still providing written evidence of the progress of the patient, some of these frameworks include narrative charting, problem-oriented approaches, clinical pathways and focus notes. Review of the literature on the frameworks that are used in documentation was the process that this article used to come up with the best framework to be used. The first framework that they reviewed was the narrative charting, which is the recording of interventions and their impact in a chronological order. They found out that this method had serious shortcomings especially in the modern practise since it involves writing a lot of notes making it difficult to retrieve relevant information, in addition, due to the large number of notes, the process is time consuming. The article also analysed the VIPS model and found out that it was time consuming among the nurses therefore not appropriate since it meant that less time would be spent giving actual care to the patients. The SOAP framework, which works well for single problem entries, was found to be ineffective to use since most of the nursing processes involves references to multiple problems making the documentation look disorganised. Clinical pathways such as the integrated Care Pathway (ICP) can be used to standardise the documentation process ...Download file to see next pagesRead More
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