PROPER DOCUMENTION AS PANACEA TO QUALITY NURSING CARE
Documentation is vital to safe, ethical, and effective nursing practice in clinical areas. Nursing Practice requires documentation to ensure continuity of care, planning and accountability, as well as in the promotion and uptake of evidence-based practice. Ideally through documentation, nurses track changes in a patient’s condition, make decisions about needs and ensure continuity of care. However, nursing documentation has often not met these objectives.
Nursing documentation is considered as an important indicator to develop nursing care. According to patient safety law, nurses have to document nursing interventions (Ohlen, 2015). Nursing documentation can be viewed as the record of care planned and or provided to patients. It is generated information written or electronic that describes the care or service rendered to individual client or group of client. In fact it is an accurate account of what has occurred and when it occurred.
DEFINATION OF TERMS
✍Documentation: encompasses all written and electronic entries reflecting all aspects of patient care communicated, planned or given to that patient.
✍Nursing: the unique function of a nurse is to assist individual seek or well in the performance of those activities contributing to health or its recovery (peaceful death) they would have perform unaided if they have the necessary skills strength or wills to make them gain independences as rapidly as possible (virgina Herdanson)
✍Nursing documentation; is the record of nursing care that is planned and delivered to individual clients or patients by qualified nurses or other caregivers under the direction of a qualified nurse.
∆= Panacea: a solution or remedy for all difficulties
OVERVIEW OF NURSING DOCUMENTATION
The history of nursing documentation has started since the early days of Nightingale (Gogler et al. 2008). Documentation started with Florence Nightingale who documented diagrammatically causes of mortality during the Crimean War as sicknesses rather than wounds. Since this humble beginning, nursing documentation has evolved into an essential element in achieving holistic nursing care and has brought with it the obligation to document not only the performed interventions (acts of commission), but also decision processes, explanation of acts of omission, and care outcomes.
It is worth to mention that nursing documentation was improved with the introduction of the nursing process into the clinical setting (Oroviogoicoechea Elliott B, Watson S., 2008). Documentation is generally recognized across the world as one of the important duties underscoring professional autonomy and assisting nurses to apply the nursing plan of care and theories in their clinical settings (Cheevakasemsook A, Chapman Y, Francis K, Davis, 2006).
Documentation is not a task most nurses look forward to but it is something that is necessary as a health professional. It is required by legislation, regulatory bodies and employers. Documentation acts as a permanent, accurate and complete account of the care provided to each patient. In addition, it provides valuable data to assist with administrative, utilization and research efforts, and acts as legal evidence to substantiate care rendered.
PRINCIPLES OF NURSING DOCUMENTATION
Appropriate nursing documentation has various principles including:
👉clearing and consistency
(Dinah, Tecla, Millicent, Alex, Robert et al., 2013).
IMPORTANT OF NURSING DOCUMENTATIO
✍serves as communication tools within health care team
✍its ensure continuity of care
✍use to assess the quality of care rendered
✍use to assess the improvement or deterioration in patients condition
✍its serves as decision making tool in patient care
✍its serves as important evidence in legal matters
✍useful in case of legislation and regulation
✍for research purposes
✍for quality process and performance improvement
✍for nursing audit
✍it is also useful in job performance evaluation
IMPLICATION OF NURSIND DOCUMENTATION ON NURSES
🤝its serves as communication tools among nurses
🤝its protect nurses against litigation
🤝it makes nurses accountable for their action
IMPLICATION OF NURSING DOCUMENTATION ON PATIENT
🤝its improve quality of care rendered to the patient
🤝its reduce mortality and morbidity related to care rendered
🤝its allows for continuity of care
NURSING DOCUMENTATION TIPS TO STAY OUT OF COURT.
👌Fill in all blanks and lines
👌Date and time all entry
👌Document through process
👌Document all assessment
👌Document physician contact
👌Develop your own method of documentation, in essence do not follow routine method of documentation like; taken over in a fair condition due nursing care rendered, state exactly what nursing care rendered.
FACTORS THAT INFLUENCE NURSING DOCUMENTATION
In a study conducted to determine factors influencing documentation in nursing at Monze hospital by Malama and Mutinta revealed that almost all (82%) of nurses documented nursing practice although it was found that most of the nursing care documented was inadequate and incomplete. However, contributing factors to this includes;
✍Inadequate and poor staffing patterns on the wards
✍Lack of in service training on nursing documentation
✍Lack of resources; insufficient or lack of enough/appropriate sheets for documentation
✍Poor appreciation of its advantages.
My recommendation is that all nurses should develop their own method of documentation to ensure that an accurate and complete information about the patients condition and care rendered are provided and that decision makers in nursing profession in Nigeria should act regarding staffing condition as its influences the nursing practice.
Nursing documentation is very crucial in health care settings and reflects various aspects including the awareness level of nurses in their roles in providing health services in a good quality. However improper documentation does not only put the nurse at risk of litigation but also influences patients recovery. Nursing documentation have two main forms: paper based documentation and electronic based documentation. Paper based documentation has certain drawbacks such as lacking the comprehensiveness and clarity. Accordingly, a strong trend to shift paper based documentation towards electronic documentation has been witnessed but yet to be adopted in Nigeria.
Cheevakasemsook A, Chapman Y, Francis K, Davis C., (2006). The study of nursing documentation complexities, Int J Nurs Pract., 12:366 -374.
Dinah Chelagat, Tecla Sum, Millicent obel, Alex Chebor, Robert Kiptoo, Priscah Bundotich Mosol, (2013). Documentation: Historical Perspectives,Purposes, Benefits and Challenges as Faced by Nurses. International Journal of Humanities and Social Science, 3 (16): 236-240.
Gogler J., Hullin C., Monaghan V. Searle C (2008). The chaos in primary nursing data: good information reduces risk. HIC 2008 Australia’s Health Informatics Conference ISBN 978 0 9805520 0 3.
Oroviogoicoechea C, Elliott B, Watson S., (2008). Review: evaluating information systems in nursing. J Clin Nurs, 17: 567-575.
Osama A Alkouri Ahed J AlKhatibMariam Kawafhah, (2016). Importance And Implementation Of Nursing Documentation: Review Study University, Jordan. Assessed on 27th of January 2019 through http://eujournal.org/index.php/ejs/article/viewfile/6955/6671
The royal children’s hospital Melbourne, (2014). Nursing documentation. Accessed on 27th January, 2019 through http://www.rch.org.au/rchcpg/hospiatl-clinical-guideline-index/nursing-documentation/
PRESENTED BY AMINU KHADEEJAH ADEROJU
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