EGT1 Task 3

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What does it mean to document accurately 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 of difficulty of a day of work. It is hard to maintain chronological tract of the event and interactions between the patient and the team delivering the care needed. The hallmark of caring responsibly is …show more content…
Through implementation of this list, it is sought to reduce medication errors and other medical errors that arise secondary to confusing documentation. The abbreviations listed as prohibited in this list increase the risk of medication errors even when used in electronic medical records (EMRs). When it comes to providing a complete review of system, as long as the physician as validated the very first provided during the initial documentation of the history of present illness (HPI), it would become superfluous to repeat it in subsequent documents; it is only needed to document new …show more content…
It is a process in which there is also planning, implementation, and evaluation of the outcomes. This term involves critical thinking, and many prefer to use this term. Clinical reasoning is an essential part in obtaining good patient outcomes. Displaying clinical reasoning skills is equal to using proper reasoning in a clinical practice. Therefore, an active mindset and constant learning, is required to reason appropriately in practice. According to Monajemi et. al., (2013), consists of all stages of patient workup, from history taking to completion of treatment and follow-up, and it is no exaggeration to say that clinical reasoning is the practice of medicine per se.
How can you use clinical reasoning to plan the organization of a comprehensive exam? Clinical reasoning is used to plan the organization of a comprehensive exam with the logical organization of the data available. An understanding of the information necessary to proceed with a comprehensive examination, allows the clinician to elaborate a questionnaire that yields information that logically leads to a clearer analysis of it, thus, leading to better diagnosis, planning, and evaluation of the outcomes.
How will you document variations of normal and abnormal assessment
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