The nursing dissertation in a health care
setting is an integral part of documentation.
Poor nursing documentation of patient care is identified in daily nurse visit
notes in a health care setting. This problem affects effective communication of
patient status with other clinicians, thereby jeopardizing clinical
decision-making. Based on the survey in health care unit, a retraining program
is recommended to improve structured nursing documentation in a home health agency.
Nursing documentation is an essential function of professional nursing practice. The documentation should be factual, current, and comprehensive to provide consistent information about the assessment, care provided, and evaluation of patient responses to care. Current health care systems require that documentation ensure continuity of care, provide legal evidence of nursing care provided, and support evaluation of quality patient care. To enhance patient outcomes that include patient safety, accurate and complete clinical information is required as a valid and reliable source to be used for communication, quality improvements, research, and policy making.
Nursing documentation is an essential function of professional nursing practice. The documentation should be factual, current, and comprehensive to provide consistent information about the assessment, care provided, and evaluation of patient responses to care. Current health care systems require that documentation ensure continuity of care, provide legal evidence of nursing care provided, and support evaluation of quality patient care. To enhance patient outcomes that include patient safety, accurate and complete clinical information is required as a valid and reliable source to be used for communication, quality improvements, research, and policy making.
Some
essential characteristics of quality information in patient records include completeness
and comprehensiveness. Nursing documentation based on the nursing process
facilitates effective care as patient’s needs can be traced from assessment and
nurses are empowered in clinical decision-making. Criteria for effective or
quality documentation include use of common vocabulary, legible writing, use of
authorized abbreviations and symbols. Quality criteria of nursing documentation
includes completeness, quantity, legibility, patient identification,
chronological report of events, comprehensiveness of description, nursing
assessment, objective information, signature, date and timeliness.
Other
ethical issues are the incomplete documentation that cannot provide the necessary
foundation for provision of quality care, quality improvement or effective
decisions on allocation of resources. Therefore, it is crucial that nursing
assessments, care plans, implementation of interventions, and evaluation of
results should be systematically and accurately communicated through effective
documentation. Patient safety has been compromised due to failure of nurses
documenting nursing processes effectively and completely. When documentation is
inadequate, it reflects substandard care with potential for litigation.
Documentation
at health care if poorly done by nursing staff, it affects effective communication
of patient status with other clinicians, thereby affecting clinical
decision-making and patient outcomes. Poor documentation can negatively affect the
effectiveness, quality and visibility of nursing work. Good clinical documentation
is a part of quality patient care and shows accountability. Documentation of
patient services in home health care is a prerequisite for continuity of care.
Nurses use progress notes on patient care to communicate patient care, assess
and record patients’ status. Effective documentation shows evidence of care
given and patients’ responses, and evaluation of care given[1]. Ineffective
documentation may result in patients missing treatments or substandard or
inappropriate or delay in treatments. Therefore, there is a need for
improvement in the quality of patient care documented in patient records. The
importance of effective nursing documentation cannot be overemphasized, as it
enhances communication among health care team, clinical decision-making,
patient safety, quality of care provided to patients and ultimately promotes
better patient outcomes.
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