Documentation In Nursing Practice

Assignment – There are five common purposes for medical records. List each of these purposes and provide an example of each in healthcare. Having good medical records is very important, for the proper care of patients. “Medical records can be used to manage healthcare, track healthcare, provide clinical data, meet regulatory requirements, and document healthcare” (Allen, 2013, P. 57). Without the proper documentation there is no proof that it was ever done.

They should be hold accountable for any breach in protocols. • Present format for electronic documentation does not allow for comprehensive clinical documentation during follow-up visit. Efforts should be made to upgrade the electronic medical record system to the standard of that expected for a medical center and research institute. This is to allow for proper documentation according to the industrial standard, and easy retrieval of patient’s information for clinical research. There is a need to employ a clinical documentation improvement specialist (CDIS) in this

DOI: 4/16/2012. Patient is a 29-year-old male technician who sustained injury when he was 25-feet up on a ladder when the ladder slid and he fell onto the pavement. He had an open reduction internal fixation (ORIF x 2) for a compound tibia fibula fracture and had hardware removal in 4/25/2013. MRI of the lumbar spine performed on 3/24/2016 revealed L5-S1 small right paracentral disc protrusion without significant spinal canal stenosis or neuroforaminal narrowing.

Procedural and Informational Documentation All information relating to the creation and

Overall, incomplete documentation and delinquent medical records cause inaccurate reimbursement and results in inaccurate gross revenue to the hospital. It can have a negative impact on the hospital budgeting and financial planning process for the hospital. It is for this purpose that every healthcare institution should be purposeful on reviewing the accuracy and completeness in clinical documentation, no matter the cost. Even though, for most physicians, most of their time is focused on the actual care of the patient and there is little to no time to devote to extensive documentation, it is imperative to understand patient care includes both the one-to-one attention and the documentation of said treatment.

The resources above expanded on knowledge concerning the definition, evolution, proposed outcomes, research and the technology of meaningful use of the electronic health record. Nursing administrators, staff nurses, and nursing informaticists all perform an essential role in achieving meaningful use of the electronic medical record to improve patient care. Certain authors referenced other authors proving that the health information technology field is indeed a tightknit community. The resources were well written from highly credentialed authors and were, for the most part, easy to comprehend. All of these articles were written for the nursing professional with the exception of resource

Nursing Bedside Reporting, Patient Safety, And Satisfaction Scores The American Nurses Association estimates that up to 80% of serious medical errors involve miscommunication between caregivers when patients are transferred or handed off during shift report (ANA 2012). In the nursing profession change of shifts require the successful transfer of information from nurse to nurse to prevent medical errors and adverse events (Sullivan, 2010). Research shows that when patients are included and engaged in their health care there is greater potential to lead to measurable improvements in safety and quality of care.

The bedside nurse manages writing and updating the whiteboard each day using a templated board, the displayed information includes day and date, the names of the patient, bedside nurse, and primary and attending physician, family member 's phone number, diet, pain management and mobile numbers for Nurse, Charge Nurse and Nurse Assistant. This simple strategies is driving our thresholds to our benchmarks at an accelerated

In studying Registered Nursing one will find that they have to be compassionate and want to care for others. Registered Nurses assist physicians with suffering patients of any medical condition. They help to decide the patient’s medicine, treatment, recovery, and educate the them and their families on post-medical treatment. They need to have bedside manner, and be able to prepare patients for surgery. Registered Nursing careers range anywhere from critical care, oncology, mental health, to an everyday school nurse.

Using IT to reduce the number of descriptions are taking place during the same time implementation and other task occurring in the nursing unit. Challenges Experienced during an Informatics

Social media platforms continue to change the healthcare landscape by allowing for users to see a variety of information and points of view. Social media can be used for information and education, marketing, recruiting, and news updates. Healthcare organizations and consumers can utilize social media to improve health and knowledge. Social media can also be used for research, disease tracking, and to monitor trends. This paper discusses the controversial public health topic of abortion and what people are saying regarding it on Twitter.

I will summarize each outcome for the Nursing Informatics specialty. For the intent of this paper I will use outcome and competency interchangeably. The first outcome means the ability to gather healthcare information across the continuum of care; combine and utilize the information gathered to develop a process. Finally execution of that process to evaluate its ability to improve the quality of the healthcare environment. Healthcare managers are constantly assessing patients and collecting information.

LPN Scope of Practice Are you considering becoming an LPN? LPN stands for Licensed Practical Nurse. The nursing field can be a challenging, but rewarding field to enter into. Before one starts a career as an LPN, there are six questions and pieces of information that needs to be addressed in order to fully understand the role of the LPN.

Role of Graduate Nurse in Informatics are: 1) computer generated nursing care plan for each patient. 2) reminder and prompts that appear during documentation to ensure comprehensive charting. 3) help as a communication aid to other health care professionals taking care of the same patient. For example, Electronic Health Record. The role of Advanced Practice Nurses and Registered Nurses are same in Informatics regarding accessing, protecting and documenting patients Electronic Health Record(EHR).

o Food intake: Document the patient’s food and liquid intake. o Observation of the sick: Observe the patient, and document the observation. o Bed and bedding: Keep the bed comfortable, dry and wrinkle free.