Analysis of Articles Relating to the Field of Documentation in Nursing - Assignment Example

?Critical Appraisal Assignment Introduction Documentation in the profession of nursing can be defined as theprocess 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). The process starts from when a patient enters a health care facility to seek medical attention for his condition up to the point he leaves the facility. In addition, it involves a nurse recording the full account of the nurse’s assessment and care, which is planned and provided for the patient, relevant information about the condition of the patient at any point (Lippincott Williams & Wilkins, 2009, p62). 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 therefore reducing the time taken for documentation therefore increasing the time to attend to patients. Focus charting was identified as the best method to use since it provides a clear focus for the nursing notes and provides a clear framework that fits well with the nursing process that the nurses use. The implication of this process is that the process of documentation will improve in terms of accuracy and relevance while at the same time giving nurses more time to attend to the patients (Lippincott Williams & Wilkins, 2011, p95). A hospital wide nursing documentation project by Shelley Tranter The article is a clinical update that describes the process and outcome of a quality initiative aimed at improving nursing documentation in a large teaching hospital in Sydney, Australia (Shelley, 2009, p35). The project was divided into three phases where the first phase involved documentation of a policy to guide on the correct way to document clinical notes, in addition, the first phase also saw the development of a specific nursing audit tool to capture the quality of nursing documentation. The second phase of the project involved conducting of a baseline audit where the deficiencies that were identified in the audit together with the documentation program were used as a base for further education, which was phase three. The third phase was the development and implementation of education strategy from the results of the baseline audit and the documentation policy formed. The fourth phase was the audit phase where an evaluation of the nursing documentation was carried out and slight adjustments made to the scoring process. The audit was carried out in thirteen wards, which included wards from medical and surgical divisions and the oncology and aged care division. In each of the thirteen wards, two auditors selected five patients randomly and evaluated their entries for legal parameters and content analysis. The initial audit carried out in the wards found out that the compliance of mandatory parameters was above 90 per cent while parameters like patient’s name, medical record number on both sides of the paper, nurse’s name and ward location scored poorly. However, in the second audit, there were increased adherence levels with most of the parameters scoring above 90 per cent. The implication, according to the feedback from the nurses is that education strategy on nursing documentation improves adherence to nursing documentation since subsequent audits showed adherence rate of above 95 per cent (Estes, 2006, P103). Evaluation of nursing documentation on patient hygiene care by Nurcan Koksal Inan RN and Leyla Dinc, RN This article was directed by three research questions, they included the following; what was the frequency of patient’s hygiene care activities of nurses at the bedside of a patient; is there consistency between actual care given by nurses and what is documented in the patient’s medical records and the quality of nurses’ general record keeping practises (Inan & Dinc, 2013, p83). The article adopted a descriptive study technique, which combined a structured observation study and an audit of nursing records, this study was conducted in six intensive care units that included coronary care unit, thorax and cardiovascular intensive care unit, medical care intensive unit, neonatal intensive care unit, neurosurgical intensive care unit and postanaesthesia care unit. The target population was nurses working in the intensive care units, as they are usually involved in direct care of the patients. A total of 98 nurses were interviewed where 73 of the nurses were employed in intensive care unit, 10 at the thorax and lung disease clinic and 15 nurses at the neurology clinic, 13 of the nurses were excluded from the survey since they had participated in the pilot program therefore a total of 85 nurses were interviewed. Data was collected by a one researcher who observed a nurse from 8.00am to 8.00pm without interference until she completed three patient hygienic care activities. The hygiene care activities were then recorded in a structured observation form and the nursing record examined for predefined recording criteria. The study found out that oral hygiene was the most observed care followed by the names of perennial care, hand, foot, eye and bed bathing (Potter & Perry, 2009, P92). Contrary to popular studies that showed less documentation of interventions, the study found out that the consistency between hygiene care and its documentation was 77.6 per cent. Hygiene in intensive care unit is important since most of the patient in intensive care unit cannot take care of themselves therefore the study had an implication on the observance of hygiene care and its documentation in intensive care units (CARPENITO, 2009, p65). Conclusion Review of the article on the frameworks and barriers to nursing documentation showed clearly how various frameworks solved barriers that were present in nursing documentation, the article gives focus charting as the most appropriate method of nursing documentation since it is precise and easy to use among the nurses. Shelley Tranter showed that with increased education programs among nurses, the quality of documentation would improve especially among the least observed parameters such as the ward location. Oral hygiene is the most observed type of hygiene especially in the intensive care units and contrary to earlier studies that showed low levels of documentation, nurses in the intensive care unit were modest in the nursing documentation where the adherence levels stood at 77.6 per cent. References Blair, W & Smith, B (2012), ‘Nursing Documentation; Frameworks And Barriers’, Contemporary Nurse, Vol. 41, No. 2, Pp. 160-168. Carpenito, L. J. (2009). Nursing Care Plans & Documentation: Nursing Diagnoses And Collaborative Problems. Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins. Delaune, S. C., & Ladner, P. K. (2006). Fundamentals Of Nursing: Standards & Practice. Clifton Park, Ny, Thomson Delmar Learning. Estes, M. E. Z. (2006). Health Assessment & Physical Examination. Clifton Park, Ny, Thomson Delmar Learning. Guido, G. W. (2006). Legal And Ethical Issues In Nursing. Upper Saddle River, N.J., Pearson/Prentice Hall. Inan, Nk & Dinc, L (2013), ‘Evaluation Of Nursing Documentation On Patient Hygienic Care’, International Journal Of Nursing Practice, Vol. 19, No. 1, Pp. 81-87. Lippincott Williams & Wilkins. (2006). Documentation In Action. Ambler, Pa, Lippincott Williams & Wilkins. Lippincott Williams & Wilkins. (2007). Documentation. Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins. Lippincott Williams & Wilkins. (2009). Nursing Know-How. Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins. Potter, P. A., & Perry, A. G. (2009). Fundamentals Of Nursing. St. Louis, Mo, Mosby Elsevier. Shelley, T. (2009), “A Hospital Wide Nursing Documentation Project” Australian Nursing Journal. Vol 17(5). Pp. 34-36 Lippincott Williams & Wilkins. (2011). Chart Smart: The A-To-Z Guide To Better Nursing Documentation. Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins. Read More