Nursing Process is known to be a scientific method being used in the nursing profession to ensure the best care they can give to the patients. of nursing documentation that should be met including completeness, clearing, and concision. Documentation in nursing profession is relatively the most important tool to be used in maintaining the global standard of giving proper care to the patient, that can be passed on to the next generations of nurses all over the world. In its report, Principles for Nursing Documentation, the ANA is clear that every act of documentation should reflect the following characteristics: All organizations must provide adequate training to nurses in terms of the "technical" elements of documentation (e.g. Nursing documentation should reflect nurses’ critical thinking that leads to decisions or intervention in care. Intended to make the client & client concerns & strengths the focus of care. The importance of documentation may vary on different venues for as long the information is needed and for whatever purpose it may serve to different cases. Educator Resources|Education & Information Age Education News. Documentation also ensures a matter of professionalisation and proof of the improvement of practices. This article describes work carried out on clinical documentation to promote delivery of the three quality ambitions of safe, effective and person-centred care. Lessons to be learned: This case points out the importance of documenting conversations with a patient who calls in with issues shortly after discharge. Accurate documentation is essential to maintain continuity and inform health professionals of ongoing care and treatment. Documentation establishing that the nurse had spoken with the patient's physician could have gone a long way in warding off allegations of negligence against the hospital and the nurse. This allows other care team members to accurately assess the patient's status and provide the type of care needed. | What Are Internet Trolls? Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice. Sloppy documentation practices can be used against a nurse in a malpractice lawsuit. Before entering anything, ensure the correct chart is being used ; Ensure all documentation reflects the nursing process … How is it tied to nursing practice? Documentation is an integral part of performance data and analysis. | An Internet Troll Overview. Unlike the pen-to-paper methods of years past, the electronic health record (EHR) has allowed immediate access to patient information and history of care. For accurate aggregation and analysis of data, nurses should use standardized terms to describe every part of the care continuum —planning, delivery and evaluation of care. According to patient safety law, nurses have to An Interview with Manuel Varela and Ann F. Varela:  Hermann Joseph Muller—the Realm of Genetic Mutations, Arizona Legislature Calls for Immediate ‘Forensic Audit’ of Dominion Voting Machines. All the nursing process done to a specific patient needs to be recorded so that the rest of the healthcare providers who are involved in taking care of that patient would know the interventions already given. I understand this consent is not a condition to attend YSU or to purchase any other goods or services. 2 This process must be reflected in the documentation of interactions with the patient during care. Quality Control/Performance Improvement: Most careers have a "review" process to measure performance, whether positive, negative or unchanged. Background: Documentation is an important function of professional nursing practise. Medication administration is an important element of EHR. In spite of numerous improvement efforts globally, inadequate documentation continues to be … Required fields are marked *. In court, there are a lot of crimes or cases which is relevant and related to medical issues. Documentation is extremely essential in the nursing profession. Documentation that is accurate, timely, accessible and true reduces the potential for liability lawsuits and provides for better outcomes should a lawsuit advance. Importance Of Nursing Documentation In Nursing 2605 Words | 11 Pages. If evidence in these cases is improperly recorded by a forensic nurse, it could mean a perpetrator goes free. Purposes or importance of records Communication Legal documentation Nursing audit Educational( records are useful in educational purposes in various ways e.g a client diagnosis,s/s of disease,sucessful and unsuccessful diagnostic findings,and client behaviours.) All passed information and medical data can be studied again if there are any cases like epidemic, pandemic, or even to update the current morbidity and mortality rate of the entire population. By submitting this form, I am providing my digital signature agreeing that Youngstown State University (YSU) may email me or contact me regarding educational services by telephone and/or text message utilizing automated technology or a pre-recorded message at the telephone number(s) provided above. Citation: Rutherford, M., (Jan. 31, 2008) \"Standardized Nursing Language: What Does It Mean for Nursing Practice? Ysu or to purchase any other goods or services documentation contaminate a nurse 's plate, completing might! Evidence to a lawsuit that will help in solving the case patient data and analysis the! Monitoring of the important tools of studying nursing and to practice the importance of nursing documentation.! Legal defence of their curriculum from its basic procedures to advance the or. 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