There is consensus drawn over a quarter million enrolled and registered nurses in Australia by the end of 2012. It is predicting investment of Australia economy into embedding nursing education and enrolled nurses has been growing substantially (Australia’s Future Health Workforce, 2014). In this direction, the growing demand for nursing documentation suggested that improving health care imperative to the promotion of the nursing profession.
According to NMC, a good recording keeping document is a fundamental part of nursing not only because it forms a chain nursing care provision also helps in circulating information in different teams (Butler et.al, 2015). As documentation contains information of nursing process, it is a source to meet legal and professional care requirements. It is written through establishing effective communication also facilitate continuity in care operations and safety of clients. In this blog, we have tried to enumerate extended importance of nursing documentation.
Characteristics Of Documentation
- It is basically known as written record of treatment, history and responses of a client
- This contains records of reimbursement costs
- It shows the uses of nurses process and consists of information on clients condition, time delivered services (Marion, et.al, 2015)
- Ensure work responsibility and auditing
- It should meet all the legal requirements
- It should well researched and audit
Requirements Of Documentation Report
- A record-keeping should be in continuity and must be comprehensible- Health care organization have to deal with long term management problems and care settings that require continuity in nurses process. Henceforth as suggested by essay helpers the report should be comprehended and brief each minute detail of patient health and his/her treatment
- Documentation supports the allocation of resources, enables identification of risk, and early complication detection- It describes what equipment has been utilized to provide care to the patient which further helps in identifying potential risk or any early complication
- It ensures control and effective communication between clients and care giver-Creation of nurses documentation establishes effective communication between both clients and care giver. The purpose of proper documentation norms is necessarily dealing with growth and communication efficiency.
- It keeps supporting auditing and trail and development of works norms- A document should be made as soon as the patient is seen or procedure gets completed
Nursing Documentation Process
Nurses’ documentation covers a wide range of issues, systems and topics. Nurses keeping record leading continuity care, safety, quality care and compliance. As said by essay typer, several single studies provide insights into nurses record-keeping practices out which the prominent are assessments, diagnosis, planning, implementation and evaluation.
Assessments– Nurses documentation such as patient care documents, assessments of the procedure, outcomes measures serve critical information of patient’s condition. Patient documentation is frequently used by professional that are outside direct care.
Diagnosis- Nurses and other health care professionals aim to provide complete diagnostic information of the patient. When nurses’ asses clients’ condition, the next step is to diagnosis the symptoms and allow the following procedure and processes ensuring right evidence for the given services.
Planning- As per online assignment help experts data collected from the documentation used to continuously measure outcomes from the predetermined standards. Evaluation and analysis of documentation is necessary for attaining the goal of quality healthcare (Satu et.al, 2013)
Implementation- The next step is evaluation of caregiving processes measuring the impact of care giving services through evidence-based knowledge. This information can be used to applied variances and experiences measure nursing sensitivity such as National database of nursing quality indicators (James et.al, 2014)
Evaluation- at the last step standardized permeable terminology included are defined patients real conditions and evaluate a diverse range of nursing care setting.
Nursing Documentation Principles
The nursing documentation stated practice acts, governments’ regulation, organization procedure and policies. According to the American association principle, nurse documentation must be based on the following principle(Pearce et.al, 2018)
Principle 1- Documentation characteristics
- High-quality documentation must be accessible, accurate and relevant
- It should be concise, auditable, complete and readable
- It should be contemptuous, thoughtful
- It has to reflect nurses processes
Principle 2- Educating and Training
- A skillful and functional system should be utilized to form documentation
- Nurses should be enough competent and know how to support hardware
- Documentation should be captured in real-time (Spring et.al, 2010)
Principle 3- Procedures and Policies
According to essay help USA, nurses should be familiar with organizational policies related to documentation also maintain efficiency in the downtime system
Principle 4- System Protection
- Each data entered in documentation should be protected
- Patient identification has to be protected
- Confidentiality of organizational and patients information should be protected timely
Principle 5- Entries
- Entries in documentation should be accurate and complete
- Each information has to be corrected and real
- Legible and readable information must be presented
- Use standardized terminology, acronyms and symbols
Principle 6- Terminologies
As standardized information somewhere permitted accessible database, only those terms should be used that described planning, implementation and evaluating processes in a diverse setting
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In this blog, we have discussed the roles and the growing importance of nursing documentation up to an extent. We first enumerated the demand of nurses in Australia, the characteristics of documentation like a good recording keeping document is a fundamental part of nursing not only because it forms a nursing care chain provision also helps in circulating information among the professional team. In the next section, we have illustrated nurses’ documentation process whose key components are assessments, diagnosis, planning, implementation and evaluation. In next step we defined nursing documentation principle where the first principle described documentation characteristics, second – Educating and Training, third– Procedures and Policies, fourth System Protection, fifth documentation entries, and at last Principe briefed standardized terminologies information.
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Australia’s Future Health Workforce (2014) AUSTRALIA’S FUTURE HEALTH WORKFORCE –Nurses. Retrieved from- https://www1.health.gov.au/internet/main/publishing.nsf/content/34AA7E6FDB8C16AACA257D9500112F25/$File/AFHW%20-%20Nurses%20detailed%20report.pdf, data accessed on 25 November, 2020
James, S. R., Nelson, K., & Ashwill, J. (2014). Nursing care of children-E-book: principles and practice. Elsevier Health Sciences.
Marion, L., Douglas, M., Lavin, M., Barr, N., Gazaway, S., Thomas, E., & Bickford, C. (2016). Implementing the new ANA standard 8: Culturally congruent practice. Online Journal of Issues in Nursing, 22(1).
National Association of School Nurses, Maughan, E., Bobo, N., Butler, S., Schantz, S., & Schoessler, S. (2015). Framework for 21st century school nursing practice: An overview. NASN School Nurse, 30(4), 218-231.
Pearce, P. F., Morgan, S., Matthews, J. H., Martin, D. M., Ross, S. O., Rochin, E., & Welton, J. M. (2018). The value of nurse staffing: ANA principles redevelopment and direction for the future. Nursing Economics, 36(4), 169-176.
Spring, S. ANA’s Principles for Nursing Documentation Guidance for Registered Nurses [Internet]. 2010.
Satu, K. U., Leena, S., Mikko, S., Riitta, S., & Helena, L. K. (2013). Competence areas of nursing students in Europe. Nurse education today, 33(6), 625-632.