Nursing Documentation In Nursing
Introduction
The Medical Board of Australia (MBA) and the Nurses and Midwifery Board of Australia (NMBA) both recognise that good record keeping is required to provide safe, high-quality health care (MBA, 2014; NMBA, 2008, 2014). Clinical documentation reflects the assessment of the patient, the clinical findings, the plan, patient's response and outcome of care (Heartfield, 1996; Jeffries, Johnson, & Griffiths, 2010). Accurate documentation is seen not only as a record of patient care (Rodden, & Bell, 2002) but also as an essential means of communication to other health professionals (Björvell, Wredling, & Thorell-Ekstrand, 2003; Kuhn. et al. 2015).
Clinical documentation has evolved over time and has progressed from handwritten narrative …show more content…
Nurses and doctors spend an estimated 20% of their time completing clinical documentation (Ballermann, Shaw, Mayes, Gibney & Westbrook, 2011; Moody, & Snyder, 1995; Saranto, & Kinnunen, 2009; Westbrook, Ampt, Kearney, & Rob, 2008). The quality of documentation in the medical record is viewed as a reflection of the quality of care given (Irving, Treacy, Scott, Hyde, Butler, & MacNeela, 2006). Accurate documentation facilitates communication, promotes health care, meets professional requirements and helps demonstrate accountability (Sewell, Day, Tuot, Alvarez, Yu, & Chen, 2013; Jeffries, Johnson, & Griffiths, 2010). Conversely, poor documentation can affect patient care and safety, limit professional accountability and increase organisational risk (Law, Akroyd, & Burke, 2010; Scruth, 2014)
However, medical records often do not reflect the interactions between hospital staff and the clinical decisions taken regarding patients. Studies have shown the degree of care the patient has received may be under-represented in the health record (Ehrenberg, & Ehnfors 2001, Gunningberg, & Ehrenberg 2004, De Marinis et al., 2010). This study will explore the barriers that prevent health professionals from documenting in a timely and accurate manner and explore what best facilitates the process of documentation from the perspective of clinicians in
The Medical Board of Australia (MBA) and the Nurses and Midwifery Board of Australia (NMBA) both recognise that good record keeping is required to provide safe, high-quality health care (MBA, 2014; NMBA, 2008, 2014). Clinical documentation reflects the assessment of the patient, the clinical findings, the plan, patient's response and outcome of care (Heartfield, 1996; Jeffries, Johnson, & Griffiths, 2010). Accurate documentation is seen not only as a record of patient care (Rodden, & Bell, 2002) but also as an essential means of communication to other health professionals (Björvell, Wredling, & Thorell-Ekstrand, 2003; Kuhn. et al. 2015).
Clinical documentation has evolved over time and has progressed from handwritten narrative …show more content…
Nurses and doctors spend an estimated 20% of their time completing clinical documentation (Ballermann, Shaw, Mayes, Gibney & Westbrook, 2011; Moody, & Snyder, 1995; Saranto, & Kinnunen, 2009; Westbrook, Ampt, Kearney, & Rob, 2008). The quality of documentation in the medical record is viewed as a reflection of the quality of care given (Irving, Treacy, Scott, Hyde, Butler, & MacNeela, 2006). Accurate documentation facilitates communication, promotes health care, meets professional requirements and helps demonstrate accountability (Sewell, Day, Tuot, Alvarez, Yu, & Chen, 2013; Jeffries, Johnson, & Griffiths, 2010). Conversely, poor documentation can affect patient care and safety, limit professional accountability and increase organisational risk (Law, Akroyd, & Burke, 2010; Scruth, 2014)
However, medical records often do not reflect the interactions between hospital staff and the clinical decisions taken regarding patients. Studies have shown the degree of care the patient has received may be under-represented in the health record (Ehrenberg, & Ehnfors 2001, Gunningberg, & Ehrenberg 2004, De Marinis et al., 2010). This study will explore the barriers that prevent health professionals from documenting in a timely and accurate manner and explore what best facilitates the process of documentation from the perspective of clinicians in