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Practicum Experience Journal - Essay Example

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Nursing documentation can be broadly defined as the process of handling patients’ records. This is a process that consumes approximately 15–25% of the nurse’s work day (Resnick & Mitty, 2009). It…
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PRACTICUM EXPERIENCE JOURNAL Documentation can be defined as the keeping and handling of records. Nursing documentation can be broadly defined as the process of handling patients’ records. This is a process that consumes approximately 15–25% of the nurse’s work day (Resnick & Mitty, 2009). It involves five main stages that are assessment, diagnostic reasoning, planning, implementation and evaluation.
During my practicum, I observed various aspects of nursing documentation that diverged from the standard aspects of the process. Although the documentation is done electronically, it is very redundant since most of the operations are done as a formality rather than as essential operations. This was attributed to the fact that at times the nurses had little time to do the documentation, thus compiling the information inappropriately leading to loss of vital information. This problem led to redoing of a lot of documentation at later stages by the nurses. For instance, failure to record full information immediately after a home visit led to inaccurate information since errors arose later when trying to figure out what was done during the home visit.
This observed phenomenon is apparently one of the causes of the nursing shortage experienced over the recent past. Most of the nurses perceive this process of documentation as either redundant or potentially unnecessary (Lippincott et al., 2003). However, on the contrary this process is one of the most critical ones in administering effective care to patients. This is because it enables different nurses to keep track of a patient’s development even in the absence of others thus enabling proper cares by different nurses. Therefore, whether the documentation is manual or electronically, it should be done with utmost care so as to enhance accuracy in the information of patients hence efficiency of their care.
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Lippincott Williams & Wilkins., & Ovid Technologies, Inc. (2003). Nursing procedures & protocols. Philadelphia: Lippincott Williams & Wilkins.
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Resnick, B., & Mitty, E. L. (2009). Assisted living nursing: A manual for management and practice. New York: Springer Pub. Co.
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