Nursing Documentation in the Age of the Electronic Health Record - Research Paper Example

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Nursing Documentation in the Age of the Electronic Health Record Name Institution Nursing Documentation in the Age of the Electronic Health Record Introduction Health care providers and administrators view record keeping as a critical element that promotes safety, quality, compliance and continuity of service…
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Download file to see previous pages Deficiencies in nursing recording have forced the stakeholders to implement interventions aimed at improving healthcare documentation. Healthcare providers need to determine the best approaches for incorporating the elements of nursing into Electronic Health Records. Electronic documentation ensures long-term preservation and storage of records, which promotes evidence-based nursing care (Busch, 2008). Capturing nursing’s independent contributions to patient care requires proper comprehension and application of standardized terminologies that reflect the uniqueness of the healthcare systems. Correct use of standardized terminologies benefits the nursing profession through enhancing communication among the nursing stakeholders, increasing visibility of nursing interventions and facilitating assessment of nursing competency. The Focus of Documentation of Patient Care Information recording is a critical part of medical endeavor. Busch (2008) maintains that medical care requires continuous flow of information before and after each task to maintain continuity of care. The tasks in the medical care are interdependent and build on one another to achieve the goals of nursing practice. Nurses have the responsibility of managing and implementing the plans of the medical team for the patient through recording the progress towards the outcomes. Nurses collect the patient’s information during diagnosis and record the same in files kept in the hospitals. The objective of collecting this information is to enable the nurses to trace the medical history of the patients during diagnosis in order to help them identify genealogical and chronic diseases. Future nurses for patients will also need this data for understanding the earlier medicine and its effects on the patient over time. Lack of documentation may lead to lose of crucial information required by both the nursing organization and the patients (Azari, Janeja & Mohseni, 2012). Practicing nurses, therefore, need to be educated to the necessity of documenting care using standardized nursing languages in this era when sectors are rapidly embracing electronic documentation. Documentation in healthcare focuses on enhancing communication and continuity of care among the nurses and other healthcare professionals involved in the profession. Communication between the nurses and the nurses and among doctors cannot be possible, unless there is proper documentation. Doctors do not meet physically to discuss the progress of patients in most cases; documents are sent from one section of the hospital to another for the intended provider to act appropriately (Busch, 2008). Proper documentation stimulates the process of communication in the hospital, which ensures that the healthcare stakeholders achieve their objectives. Another focus of medical documentation is ensuring evidence for future reference. There are cases where doctors give incorrect medication to patients. These patients may develop complications, which may lead to legal liabilities. The courts of law require the records to serve as evidence for incorrect treatment disseminated. Documentation ensures that these records are available whenever required. Additionally, proper documentation leads to recording of data that is crucial for research and education (Ripley, 2009). Practicing students of medicine and nursing can refer to these documents when there is a need to link theoretical knowledge to practical knowledge. Documentation, ...Download file to see next pagesRead More
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