Documentation and Record-Keeping in the Nursing Profession and Medical Endeavor - Essay Example

Name: Institution: Unit Title: Date of Submission: Tutor: Table of Contents Executive summary Documentation and record keeping are some of the critical parts of the nursing profession and medical endeavor in general. Documentation plays various roles in the healthcare set up which benefits the patient, health organization, healthcare providers, the client’s family and significant others. Therefore, this essay will analyze in detail documentation as a tool used in the healthcare setup. This includes analyzing ways in which documentation process is done, its uses and benefits of documentation in the healthcare set up. The analysis is carried out taking into consideration the link provided in class for individual analysis. Introduction Documentation in the nursing profession is one of the tools used to support evidence of continuous and share understanding of the patient’s care and history. The tool aids in promoting intra-disciplinary and inter-disciplinary communication, actions and decision making on the patient’s future care. As a tool, documentation plays a role of ensuring that patient’s safety, quality care provision and continuity of care is provided to the patient. Other than monitoring the patient’s health and progress, documentation is used to ensure patients safety, as a legal document and continuity of care provision to the patient. Detailed description of the documentation process Hauptman, 2008, states that nursing documentation is inclusive of varied systems, topics and issues affecting the quality of healthcare provision to the clients. This creates a link between maintenance of patient’s safety, compliance to treatment, provision of quality healthcare and continuity of care to proper documentation and record keeping. One of the information documented by the nurses is the client’s assessment data. This includes deliberate and systematic collection of patient’s information to determine client’s current and past functioning which influence the current health status (Joint Commission, 2008).  Additionally, the nurse documents diagnostic information obtained from analyzing the collected assessment data. The nurse then documents the plan of care in order of priority and come up with the expected outcomes of the chosen plan of care. The nurse also documents the implementation actions taken to allow the patient achieve the desired outcomes. Finally, the nurse evaluates the effectiveness of the chosen intervention. This includes evaluating whether the desired interventions were achieved and whether the interventions should be re-designed to improve the client’s outcomes (Hauptman, 2008).  Therefore, nurses should possess vast knowledge on various areas including human anatomy and physiology, microbiology and pharmacology to ensure effective nursing care provision and proper documentation. Understand anatomy will enable the nurse describe anatomically the body areas affected by a disease or injury enhancing communication among the healthcare providers. Knowledge on physiology will enable the nurse to come up with effective nursing diagnoses and interventions that should be employed to improve the patient’s outcomes. Additionally, knowledge on physiology will enable the nurse understand the pathology underlying patient’s condition (Peate & Nair, 2011).  Furthermore, knowledge on microbiology will enable the nurse to understand various mechanisms of disease spread within the healthcare facility and at the community set up. Therefore, the nurse will be able to come up with interventions to minimize and prevent disease spread in the population. Furthermore, nurses should have adequate knowledge in pharmacology. This will enable the nurse understand the basic rules of drug administration, calculating drug dosage, understand drugs side effects and adverse effects. Pharmacological knowledge will help nurse document patient’s needs accordingly such as adverse drug reaction, side effects, and contraindications (Bohra & Sinha, 2012).  Documentation Guidelines One of the documentation guidelines which the nurses should take into consideration as identified from the link is the objectivity of the documentation process. Objectivity ensures that complete and accurate documentation is conducted by the nurse. Objective results are obtained from making observations and conducting various clinical measurements. Thus, nurses should document what he/she sees, smells, hears or feels. Correct spellings and abbreviations should be used to communicate measurements obtained from the client. Recording objective results should be written legibly to enhance its clarity. This should be done using black and blue ink (Johnson & Bade, 2010).  Additionally, nurses should take into consideration the timeliness when documenting client’s information. This includes the frequencies in which nursing care is provided to the client. Including time in the documentation process enhances accuracy and credibility of the healthcare records and client’s care information. Therefore, when documenting the client’s care, date; 24 hour recording should be adopted. However, factors such as organization’s policies, complexity of the health issue, client’s condition and risks involved in nature of care provided should be taken into consideration as they influence the frequency of documentation (Ruping, 2009).  Errors during documentation process should be underlined using a single line rather than using white out eraser. This ensures accountability and responsibility in the documentation process. Nursing and other medical documentations should not have empty spaces or lines. To prevent manipulation of client’s and nurse’s information, empty spaces and lines should be completed by drawing straight lines. Time when nursing interventions and assessments are done should be properly documented (Lippincott & Wilkins, 2007).  Documentation should be a comprehensive process to enhance communication between various healthcare providers. Abbreviations used should be accepted in the concerned healthcare organization. Using accepted abbreviations minimize incidences of errors in the documentation process and enhances communication between healthcare providers. At the end of every documentation process, nurses should sign against their names and their designation to enhance accuracy, accountability and responsibility. However, additional information to be documented after recording specific information should be indicated as an addition with the nurse’s signature and designation (Lippincott & Wilkins, 2011).  Additionally, patient’s progress information should be documented. This includes patient’s identity, current situation and health status. Discharge plan should indicate the person responsible for continuing the provision of care to the client after discharge. Specific instructions to the patient should be documented. This includes information regarding client’s next appointment (Faltin, et al. 2012). Information related to the patient’s referral to a different health institution should also be documented. These include information such as assessment findings, interventions and reasons for transfer and signed with nurse’s designation. Factors such as patient’s information privacy and understanding institution’s legal regulations should be considered by the nurse when using electronic documentation. Other information documented includes administration of medication, calls made by the patient and any emergency care provided to the customer (Carpenito, 2009).  Detailed description as to why documentation is performed and practice One of the key reasons as to why documentation is carried out at the healthcare facilities is to be used as a communication tool within the healthcare set up. Nursing care provided to the client is documented upon which other nurses can evaluate the effectiveness of the care provided. Documentation is used as a tool for ensuring that patient receive continued healthcare. Regular documentation ensures that the patient receives focused healthcare aimed at eliminating health problem and promoting patient’s positive outcomes (Bjorvell, 2002). Additionally, documentation ensures the healthcare providers are held accountable for their actions and decision making on the nature of healthcare being provided to the clients. Through documentation, nurses are able to practice in accordance with the stated nursing practice standards, practice competently and apply their nursing knowledge and skills in providing nursing therapeutic care to those in need. Documenting holds nurses responsible for their actions and decisions related to the nature of healthcare provided to their clients. Accurate documentation reflects organization’s dedication to provision of holistic care with the desired professional and personal support to their clients (Mahler et al. 2008). Furthermore, it is used for legal proceedings. Accurate documentation provides legal evidence that the nurse provided the necessary care required as stipulated by the state’s nursing practice regulations. As a legal document, documentation can be used as a tool for resolving conflicts on issues related to responsibility and accountability of care provision. Documentation provides vital information which can be used for improving the quality of care and managing risks. It provides basis for measuring quality of care and evaluation of the client’s progress towards achieving the desired outcomes (Keenan et al. 2010). Documentation provides the healthcare providers with the basis for identifying, and assessing risks that are likely to affect the clients, organizational assets, visitors and staff. Therefore, through documentation; the organization is able to come up with risk management strategies that enhance the safety of the clients, staff, visitors and organization’s assets. Documentation enhances the efficiency in which healthcare services are provided. This is attributed to enhance communication, increased responsibility and accountability in the healthcare facility (Practice, 2008). Finally, documentation facilitates provision of evidence based care and practice to the clients. Proper record keeping offers an important source of information which can be used for conducting nursing research on various issues affecting the nursing practice. Additionally, documentation delivers vital information such as effective nursing interventions and evaluation of the patient’s outcomes (Lippincott & Wilkins, 2008). Documentation provides the nurses with opportunities to carry out self-reflection on the effectiveness of nursing care provided. Through the reflections, nurses are able to gain insights on effective nursing interventions which can be provided to enhance quality nursing care provision to the clients (College & Association, 2009). Conclusion From this analysis, it is evidently clear that documentation plays a vibrant role in contributing to quality care provision, enhancing healthcare providers’ accountability and responsibility for their actions and decision making process. Therefore, health care organizations should consider providing educational facilities to their employees to enable them understand the basics of new documentation techniques such as electronic documentation. Additionally, nurses should recognize that patients are central in the care provision hence; their needs should be catered for. However, this analysis has not analyzed the issue of documentation in the required depth. Therefore; further study into the topic is highly recommended. References Bjorvell C. (2002). Nursing documentation in clinical practice: Instrumental development and evaluation of a comprehensive intervention program. Stockholm: Karolinska Institute. Retrieved from : http://openarchive.ki.se/xmlui/bitstream/handle/10616/38039/thesis.pdf?sequence=1. Accessed on, 8th Sept. 2013. Bohra, J. S., & Sinha, S. K. (2012). Introducation to microbilogy. Jaipur, Oxford book company Carpenito, L. J. (2009). Nursing care plans & documentation: nursing diagnoses and collaborative problems. Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins. College & Association of Registered Nurses of Alberta (2009). Documentation guidelines for Registered Nurses. Edmonton: College and Association of Registered Nurses. Retrieved from: http://www.nurses.ab.ca/Carna-Admin/Uploads/Documentation%20for%20Registered%20Nurses.pdf. Accessed on 8th Sept. 2013. Faltin, F. W., Kenett, R., & Ruggeri, F. (2012). Statistical methods in healthcare. Chichester, West Sussex, Wiley. http://public.eblib.com/EBLPublic/PublicView.do?ptiID=978385. Hauptman, R. (2008). Documentation: a history and critique of attribution, commentary, glosses, marginalia, notes, bibliographies, works-cited lists, and citation indexing and analysis. Jefferson, N.C. [u.a.], McFarland. Health Professions Institute. (2013). Medical transcription: fundamentals and practice. Upper Saddle River, N.J., Prentice Hall. Johnson, T. E., & Bade, D. L. (2010). Export/Import Procedures and Documentation. New York, AMACOM. http://public.eblib.com/EBLPublic/PublicView.do?ptiID=495276. Joint Commission Resources, Inc. (2008). A practical guide to documentation in behavioral health care. Oakbrook Terrace, IL, Joint Commission Resources. Keenan G. M, Yakel E, Tschannen D. & Mandeville M. (2010). Chapter 49. Documentation and the Nurse Care Planning Process. New York: Sage. Retrieved from: http://www.ahrq.gov/professionals/clinicians- providers/resources/nursing/resources/nurseshdbk/KeenanG_DNCPP.pdf. Accessed on 8th Sept. 2013. Lippincott Williams & Wilkins. (2011). Chart Smart: the A-to-Z guide to better nursing documentation. Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins. Lippincott Williams & Wilkins. (2007). Documentation. Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins. Lippincott Williams & Wilkins. (2008). Complete guide to documentation. Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins. http://www.r2library.com/public/ResourceDetail.aspx?authCheck=true&resid=626. Mahler C. Eichstadter R. & Haux R. (2008). Nursing process documentation systems in clinical routine- prequisites and experiences. Ontario: Elsevier. Retrieved from: http://www.lina- schwab.de/Publikationen/z8.pdf. Accessed on 8th Sept. 2013. Peate, I., & Nair, M. (2011). Fundamentals of anatomy and physiology for student nurses. Chichester, West Sussex, U.K., Wiley-Blackwell. Practice Standards (2008). Documentation Revised. Ontario: College of Nurses of Ontario. Retrieved from: http://www.cno.org/Global/docs/prac/41001_documentation.pdf. Accessed on 8th Sept. 2013. Ruping, A. (2009). Agile Documentation a Pattern Guide to Producing Lightweight Documents for Software Projects. Chichester, John Wiley & Sons. http://public.eblib.com/EBLPublic/PublicView.do?ptiID=220524userid=^u. Read More