Patient reports she took pain med for chest pain. Proper documentation serves many purposes for patients, physicians, nurses and other care providers, and families. Why Is Documentation Important in Nursing. Nursing Informaticians Address Patient Safety to Improve Usability of Health Information Technologies. Part of the HIPAA legislation also allows the patient to request their medical records. Complete documentation ensures all of the unit policies for documentation are addressed.
Allows for increased safety checks. It makes your work easier because you no longer need paper charts at the nurse's stations anymore. And then there are a few who are very good at it, and the days they are not here, then it will not be done. This starts the domino effect.
Document changes in the patient's condition. Grammar and syntax problems are frequently at the heart of documentation bloopers. Stimmel defended one case where a patient's wound or bed sore was described completely differently by two nurses who saw the patient with the same hour. Think about the last difficult shift you had. Laboratory test results. One strength of this study is that the sample included a combination of healthcare professionals with considerable experience and bachelor-degree students with an outside view of the workplace. The Permanente journal, 12(3), 25-34. This theme includes two sub-themes and refers to the barriers associated with personal characteristics that may influence a staff member's documentation practices. The following are a few examples of the clinicians who contribute to or review the patient's medical record: - Medical Team: physicians, nurse practitioners, physician assistants, surgeons, specialists, residents. The Link Between Nursing Documentation and Therapy Services. How can we prevent these types of errors? Nursing documentation: if you didn't chart it you didn't do it | missing nursing documentation. These actions will help you gain the most benefit from the EHR: Document promptly and thoroughly.
Plus, improper documentation can open up an employer to liability and malpractice lawsuits. DOCUMENTATION DOS AND DON'TS. Phone calls made to patients and/or families may also become a part of the medical record. This way, it becomes much easier for you to work on preventive as well as curative measures. The student groups, in particular, felt unsafe when nurses used phrases and words not familiar to them; however, staff informants also expressed problems with individual approaches toward documenting language, subsequently making it difficult to contextualize follow-up activities. Ultimately, it is also a legal document and may be used in a court of law as applicable. "I just love charting, " said no nurse, ever. If it's not documented it didn't happen nursing research. To enhance and secure patient safety, increased individual, social, organizational, and technological support is necessary to overcome these barriers to ensure that optimal patient information is available when required for nursing care. Home ED Legal Letter September 1, 2010 This is the second of a two-part series on documentation and ED liability. Too often nurses view EHRs negatively, feeling they're cumbersome and take nurses away from the patient. Use notes appropriately.
If not, how can you change your practice to improve your documentation? Join Expert Network. Do not speculate data. "The patient has done well without oxygen for the past year. " It allows clinicians to keep track of all the care that has already been completed for the patient. Timely: What occurred during the shift should be documented during the shift. Past medical history: surgeries, chronic conditions, family history, allergies, and home prescriptions. Other discrepancies involve the use of different types of graphic records, with some nurses using a slash in a box, others circling a box, and some placing an X in the box. Ask yourself... - What are your experiences with charting? Avoid abbreviations that are non-medical, which can result in interpretation errors. In a staff focus group, one informant told: Yes, we can wait for several days for answers for blood samples (…), and quite a few nurses get frustrated. Regardless, accurate and complete documentation is essential. If it's not documented it didn't happen nursing teaching. All entries are date and time stamped.
On the other hand, one may also consider this as a strength, because all informants reported on their experiences from a common starting point when describing their challenges. If it's not documented it didn't happen nursing homes. Independent Medical Examination (IME)/DME. The Student understands and agrees that NCC shall not be held liable for any acts, errors, advice or omissions provided by the Student based on knowledge or advice acquired by NCC. The information provided in this course is general in nature and is not designed to address any specific situation.