12. What Are the Principles Underpinning Nursing Documentation Including Legal Obligations

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When caring for a patient, it is important to ensure good accounting to promote patient care and better communication. Good records are the product of good teamwork and an important tool for developing quality health care and enhancing professionalism in nursing. For those who don`t know, telepraxia of nursing covers different types of nursing services and remote care services. For example, it includes care provided by videoconference or by calls from a hospital to a remote area. In addition, this care documentation also covers advice to public health authorities and insurance companies. Documentation should be provided when health care or advice is provided without personal contact with the patient. Legally, records and documentation are great ways to protect health professionals and nurses. This is because proper registration helps protect the health care provider when a legal defense is needed. Not to mention, he provides practical evidence and demonstrates professionalism. If you want to know more about care documentation, we have everything in this article! A well-kept register can protect the practitioner in cases where the legal defense of his actions is required. The documentation also ensures a question of professionalization and proof of improvement of practices.

Care notes are intended to provide data and information about the patient`s progress in developing expected outcomes. It contains information about the patient`s problems, as well as nursing interventions. In the next section, we share the guidelines and factors to consider when writing maintenance notes for computerized reports, such as: Maintenance documentation can be supplemented by various methods, such as problem-oriented diagrams and source-oriented diagrams. There is also a method called narrative mapping. The maintenance documentation also includes diagrams according to extraordinary and critical paths. The care documentation is tailored to the “care process” and reflects the principles of assessment, planning, implementation and evaluation. It is ongoing and should be reflected in the documentation of care. Computer-aided documentation in nursing is a decisive factor in clinical documentation. However, it is common for care documents to lack quality and efficiency, but computerized documentation can support and improve quality. This computer-aided documentation promises completeness, quality and improves formal aspects. It is therefore crucial to stay informed about legal requirements and best practices for record keeping and to prove that these standards also provide the infrastructure for routine healthcare for clients.

In most cases, graphs are created, except on clinical pathways, flowcharts, and care maps designed according to predetermined processes and protocols. However, if the patient`s condition is different or deviates from established standards, additional documentation may be required. However, mapping exceptionally requires the availability of appropriate clinical pathways, standards and guidelines. Only standard medical and nursing terminology and community-approved abbreviations and symbols should be used. When it comes to computer-aided documentation, optimizing UX design for medical devices also plays a key role. The common function is supposed to be efficiency in obtaining documents, but a well-designed computerized documentation system promises document security while improving the user experience. Provide a structured and standardized approach to nursing documentation for inpatients. This ensures consistent clinical communication processes throughout RCH. Computer-aided nursing documentation is defined as the documentation of a patient`s care by computer.

For example, it includes vital signs from health monitors as well as clinicians and care assessments. Computerized nursing documentation has several advantages, including the following: These systems provide the standard documentation form shared by the entire healthcare team. However, if not used correctly, critical thinking processes are reduced and they can even rely on bypass forms. In addition, errors may also occur. So, if you want to properly write the interview documentation with the EHR, you can follow the tips below; At the beginning of each shift, a “shift assessment” is conducted as described in the Nursing Assessment Guideline. Information for this assessment is collected from the transfer, patient presentations, required documentation (safety and risk assessments, clinical observations) and an EMR review and documented in the corresponding “flowcharts”. The EMR examination provides an overview of the patient. To perform an EMR exam, enter the patient`s medical record and work on the most important activities in the correct order.

These tabs can be tailored to the specific needs of your patient group (link to emR tip sheet – coming soon). It is recommended that each department standardize the layout of its activity bar according to its patient population. The EMR review should include: (*indicates that it is an important document); An accurate written record detailing all aspects of patient monitoring is important, not only because it is an integral part of patient care delivery or care management, but also because it contributes to the dissemination of information between the different teams involved in the treatment or care of the patient. It should describe the need for documentation (if necessary) as well as resources and checklists to support the care documentation. Clinical technologies and information systems play a crucial role in documenting health care. It is important to take into account the quality and safety requirements that may arise when implementing or designing computerised documentation. You are expected to be able to meet the record keeping requirements set by your employer or organization. This means that you: All entries must be correct and relevant to the individual patient – non-specific information such as “continuous management” is not helpful. Duplication of work should be avoided – statements on information recorded in other EMR activities are not useful, for example: “medicines administered in accordance with the MRA”. Professional nursing language should be used for all entries – abbreviations should be used to a minimum and should comply with RCH standards, e.g.

“emotional support was provided to the patient and family” could be documented instead of “TLC was given”. Real-time notes must be approved as an addendum after the first entry and subsequent entries. Therefore, you need to be careful about what you write. Not only will you be asked to formally explain your records in the event of a patient or client complaint, but registered nurses also have professional and legal due diligence. EHR management systems have become extremely important for healthcare facilities with the digitization of records. However, certain guidelines must be followed when documenting care records, for example: All computerized documentation must comply with the standards and essential elements of the documentation. Not to mention that it must support clinical communication. The EHR should include patient health information such as diagnoses, medical history, vital signs, patient demographics, allergies, laboratory reports, vaccinations, and billing data. A registered nurse is responsible for any delegation of records to multi-professional team members who are not registered practitioners, such as entry-level physicians (PAs), practical nurses, and nursing students (Jevon 2012).

The care centre is a shift planning tool and provides a schedule of care plan, including ongoing assessments, diagnostic tests, appointments, scheduled medications, procedures and tasks. Orders fill the hub and nurses can document directly from the hub in real time in treatment schemes. The orders are visible to the multidisciplinary team. Computerized systems can improve care documentation by providing faster access to the update platform. These computer-aided documentations are actually more convenient to read than to write. This will eventually reduce the likelihood of misinterpretation and errors, as this can lead to inefficient quality of patient care. Complete and accurate documentation provides legal protection to the nurse, other health professionals in the facility and the client. It`s quite explainable because you shouldn`t draw anything that didn`t happen.

It also contains the symptoms, because if the symptom does not exist, you should not write it in the documentation. Healthcare organizations must ensure that they meet standards and documentation requirements. For example, the workforce should be helped to provide correct information materials. In addition to adding patient records, EHR management systems should describe the roles and responsibilities of health care workers.