Documentation In Nursing Practice

Words: 481

Pages: 2

Documentation is anything written or electronically generated that describes the status of a client or the care or services given to that client (Perry, A.G., Potter, P.A., 2010). Nursing documentation refers to written or electronically generated client information obtained through the nursing process (ARNNL, 2010).
Nursing documentation plays a significant role in nursing practice. Documentation can be either paper or electronic which is used to observe the improvement of a client. It a way to convey information such as assessment, interventions require with reference to the client’s history along with the effectiveness of those interventions. It also encourages continuity of care as it allows other members of the healthcare team to access

Show More

MO/270 Case Study Research Project

Case Study Research Project Final Paper LaNetria Triggs Instructor: LeAnn Lupton Case Study Research Project MO 270 (3/9/18) Introduction In this essay, I will be discussing several different topics such as documentation, medical practice, communication, billing and reimbursement, various diseases and treatments processes, and diversity. The purpose of covering these topics is to better educate the concepts and perspectives of these topics. Often times, people seem to have misconceptions…

Words 1082 - Pages 5

Health Information Management

Association (2010) the use of a standardized nursing language for documentation of nursing care is both vital to the nursing profession and to direct nursing care. As of 2008 the American…

Words 1734 - Pages 7

Critical Thinking Essay

Running head: CRITICAL THINKING 1 Critical Thinking in Nursing Practice Scott Rhoades Walsh University CRITICAL THINKING 2 Critical Thinking in Nursing Practice Nurses initially learn to appreciate what the field and profession has to offer them. They learn and establish ideas, concepts and theories of nursing and develop intellectual capacities and skills so that they become disciplined, self-directed, critical thinkers. So they may be able to think in a systemic, holistic…

Words 640 - Pages 3

Nursing Ethical Dilemma Paper

Ethical Dilemma Ethical Dilemma Ethical issues are part of nursing throughout practice, often resulting from conflicts between principles and norms. These conflicts strongly influence the nursing practice regarding the decision-making process, patient outcomes, and moral climate within healthcare organizations. This paper will focus on a specific ethical issue in nursing, analyzing the ethical issues involved in the practice. This will entail looking at important principles of bioethics such as…

Words 1384 - Pages 6

Essay about Professional Portfolio: Tracking Personal Development

competence to practice nursing (Mills, 2009). It can also be used to help record one’s best work and accomplishments over at least a three year period, assisting in marketing that person’s attributes to future employers and businesses. A portfolio can include a number of items to showcase a person’s quality, such as a letter of recommendation, resume/ curriculum vitae, a record of academic experiences, selection criteria relevant to the job position being applied for, reflective practice pieces (which…

Words 992 - Pages 4

EGT1 Task 3

and appropriately? The quality of nursing documentation is still a challenge in the nursing profession and, thus, in the health care industry (Dehghan, Dehghan, Sheikhrabori, Sadeghi, & Jalalian, 2013). Keeping documentation accurately and appropriately, while dedicating our time to patient care is tantamount to delivering safe care; it is part of our duty to work and develop a safe environment. The quality of our documentation reflects the quality of our nursing care despite of the acuity or level…

Words 1232 - Pages 5

Discharge Learning Case Study Essay

INTRODUCTION In this case study, Mr. Mustafa, a registered nurse, neglected the codes of conduct, ethical principles, and standards of practice for nurses, as he failed to assess neurological observations on an 80-year-old resident named John after he fell in an aged care facility's dementia unit in Melbourne, due to Mr. Mustafa being busy with documentations and doctors’ rounds. Alarmingly, Mr. Mustafa did not record the fall-in-history medical records. John seemed settled without any reason for…

Words 2169 - Pages 9

Legal and Ethical Parameters of Professional Nursing Practice Essay One

professional nursing practice essay one Professional nurses encounter a variety of legal ethical and bioethical issues on a daily basis. For this reason, it is essential that all nurses are aware of current state and national legislation, acts and guidelines and the implications of these for nursing practices as well as legal processes, principles of open disclosure and the role of a coroner in the health sector. In this way, nurses can adhere to the overarching guidelines for practice as well as…

Words 895 - Pages 4

Nurse Informatics Analysis

The Role of Informatics Nurse The field of nursing is unique. It has allowed the nursing profession to flourish and branch out to different expert areas such as advanced nursing practice, legal nursing, and nurse anesthetist. One of the area that nursing has explored is nursing informatics. American Nurses Association (ANA) defined nursing informatics (NI) as an integration of nursing science, computer science and information science to manage and communicate data (McGonigle & Mastrian, 2012). It…

Words 756 - Pages 4

Organizational Change Plan

Veterans Affairs, 2010). Therefore, to provide and maintain excellence in care, it is necessary to improve constantly. Health laws require documentation of nursing interventions performed and evaluation of the care given to ensure and improve nursing care quality (Muller-Staub, 2009). In 2001, the MVAMC changed the paper-based nursing documentation system to…

Words 1255 - Pages 6