Language can be an example of poor documentation practices in patient records because it has to be specific, objective, and factual. An example would be a nurse documenting about a patient “appearing to be looking good” the nurse was using vague words and speculating. There needs to be specific facts that the patient is doing well by documenting the patient’s temperature or the reaction to the medication taking affect. Vague words can cause problems to the healthcare provider because the nurse didn’t describe facts and the provider needs facts to prove that the patient is doing well and not send them home still feeling ill. This could cause problems with the patient because the patient may be feeling the opposite and feel ill instead of good.
These are Verbal, Non-Verbal and Written communication. Verbal communication refers to spoken contact between individuals, Non-Verbal is unspoken communication such as body language and written communication that uses a different pathway such as a letter. The success of verbal communication is dependent on precise, well defined, clear and age appropriate contact (RCN 2015). For example, a paediatric patient’s diagnosis may be approached with a less detailed account of the illness, thus not to confuse the individual or provoke fear. Furthermore non-verbal communication constructs a large percentage of paediatric nursing cases, due to circumstances where verbal communication is not possible. Patient-oriented care is vital for growing an understanding of the individual’s non-verbal signs of pain, which expressed the importance of actively looking for distress signals (Mattsson 2002). Finally written communication acts as the record keeping and documentation element of nursing care, which is a fundamental skill for all medical staff (NMC 2002). Incorrect written communication can lead to individual missing key changes in a patient’s condition thus leading to a potential fall in a patient’s health (Inan and Dinc
Thoroddsen, Asta, and Margareta Ehnfors. "Putting policy into practice: pre‐and posttests of implementing standardized languages for nursing documentation." Journal of clinical nursing 16.10 (2007): 1826-1838.
Documentation is key in defending oneself, especially when cases are brought up, as my classmates mentioned, many years after the fact. Documentation is also important in order to provide a flow or a routine in the care being provided. For example, Nagelhout’s book talks about the flow of anesthesia practice during induction, in almost all
To those unfamiliar with medical records, review of documentation can be a challenge. Medical records include many abbreviations and medical terminology composed of Latin and Greek terms. Some abbreviations, such as PT and DC, have more than one meaning. Not much attention is paid to punctuation and grammar in medical records and spelling errors can make them difficult to read. Legal nurse consultants play a pivotal role not only in translating medical records but in identifying their legal significance, including standards of care, causation and damages. But even LNCs can have trouble interpreting records when the handwritten documentation is illegible.
Poor order transcriptions and documentation of orders given by doctors to nurses whether it’s verbal, written or over
Effective communication prevents medical errors, improve patient- therapist relationship, as well as prevents disappointments and friction. It is essential to find out the level of health literacy of an individual, as well as the proficiency in English. According to Divi, Koss, Schmaltz & Loeb (2007), there is a risk of patient 's safety due to the language barrier. Based on the study of Divi et al. (2007), among 832 English speaking patients and 251 patients with limited English fluency, 49% of the patients of their study have limited English fluency that associated with physical harm with a rate of 29.5% patients that are fluent in English are physically injured. Partially injured and death occurs with patients with constrained English proficiency (52.4%), as compared to patients with English fluency (35.9%) (Divi et al., 2007). Divi et al. (2007) suggested providing access to qualified language interpreters for patients with limited English proficiency to prevent more harm. Effective communicating is not only important to patients with limited, or inadequate English proficiency but also to individuals with impaired vision, hearing, and people that unable to speak.It is also important about the patient 's privacy. Another knowledge from the book mentioned above is effective communication regardless of individuals culture.
Every patient's medical records are different some contain more information due to their medical history. If a patient has alot of problems and have been treated then their file would have more information . Certain records also contain history of complaints and procedure, few records have photographs with a short summary of what is present. Medical records can be electronically stored , traditioanlly handwritten and even voice recorded. Medical records that are written on paper and kepted in folders are divivided into informative sections It contains medical terminology terms that any person in the medical field can read It should be written in either black or blue ink. Each provider should always document the evaluation and results of every visit during the visit. It is prohibited to pre-date or backdate an entry. If there is to be a mistake written in a wrong patients file it should be dated and signed by the person that is revising the file; this shows proof that it was corrected..
The purpose of this paper is to identify a quality safety issue. I will summarize the impact that this issue has on health care delivery. In addition, I will identify quality improvement strategies. Finally, I will share a plan to effectively implement this quality improvement strategy.
this will cause healthcare providers with the training and education needed for clinical documentation improvements to be installed effectively. It is important that having a specialized team who can create solutions towards Clinical Documentation Improvement (CDI) in order to minimize the failures that may occur. In this case, investing in training for the materials/tools necessary for healthcare providers to excel in their work with CDI. Essentially, Clinical Documentation is used throughout the healthcare system for the analysis of care, communication, and medical records. This is important because the information of medical records that healthcare providers are able to access, will help patients track their health conditions. Thus, clinical documentation improvement has a direct impact on patients by providing quality information. On the other hand, the new technological advancements will also be able to address the efficiencies in health care system that differ from paper-based charting. Improving on the quality of information will also have the effect upon the ethical and effectiveness of care that is being provided. This has a significant impact in order to maintain patient care that ensures the documentation is accurate, timely, and reflect within the services provided. Documentation assessments can be utilized so there can be improvements on the education for healthcare providers as they intend implementation standards take effect immediately. In this case, failures must be analyzed so that they will have the ability to comprehend and determine an organization’s strengths and weaknesses
Communication encompasses a wide range of processes such as the exchange of information, listening, posing of questions (Fleischer et al., 2009) or use of body language. In a healthcare environment where there are constant interactions among nurses, doctors, patients and other health professionals, professional and effective communication is important in ensuring high quality healthcare standards and meeting the individual needs of patients.
Health information opponents has question the delivery and handling of patients electronic health records by health care organization and workers. The laws and regulations that set the framework protecting a user’s health information has become a major factor in how information is used and disclosed. The ability to share a patient document using Electronic Health Records (EHRs) is a critical component in the United States effort to show transparency and quality of healthcare records while protecting patient privacy. In 1996, under President Clinton administration, the US “Department of Health and Human Services (DHHS)” established national standards for the safeguard of certain health information. As a result, the Health Insurance Portability and Accountability Act of 1996 or (HIPAA) was established. HIPAA security standards required healthcare providers to ensure confidentiality and integrity of individual health information. This also included insurance administration and insurance portability. According to Health Information Portability and Accountability Act (HIPAA), an organization must guarantee the integrity, confidentiality, and security of sensitive patient data (Heckle & Lutters, 2011).
Despite the frequency of verbal interactions, miscommunication of patient information occurs that can lead to patient safety issues. . . . ‘Effective communication occurs when the expertise, skills, and unique perspectives of both nurses and physicians are integrated, resulting in an improvement in the quality of patient care’ (Lindeke & Sieckert, 200...
"A Guide to Taking a Patient's History” is an article published in an August 24th, 2007 issue of Nursing Standard. Written by H. Lloyd and S. Craig, the process of taking a history from a patient is outlined. Many aspects pertinent to obtaining a sufficient health history are discussed. In addition to providing a framework for completing a thorough health history, guidelines and interview techniques are explored.
Documentation is a form of communication that provides information about the patient and confirms that care was provided to that patient. Some reasons why nurses document is for communication and continuity of care of the patient and by that it means clear, complete and accurate documentation in a health record ensures that all those involved in a client’s care, including the client, have access to information upon which to plan and evaluate their interventions. Next, quality improvement/assurance and risk management through chart audits and performance reviews documentation is used to evaluate quality of services and appropriateness of care. Additional reason is it establishes professional accountability because documenting that is showing a valuable method of demonstrating that nursing knowledge, judgment and skills have been applied within a nurse-client relationship in accordance with the Standards of Practice for Registered Nurses. Another purpose is for legal reasons the client’s record is a legal document and can be used as evidence in a court of law or in a professional conduct proceeding. Courts may use the health record to reconstruct events, establish time and dates, and refresh one’s memory and to substantiate and/or resolve conflicts in testimony. Although you may never be named as a defendant in legal case, you may be called to testify at a discovery or
In the article “The Study of Nursing Documentation Complexities”, the multiple authors came together and informed us as readers about the importance of documentation within nursing. Documenting information about the health care plan of a patient is not just for the sole purpose of communicating between healthcare workers. It can also be used for a variety of things, such as helping provide researchers with conducting data, as well as helping the development of education within this field.