Nursing Documentation In Nursing

6. SOCIAL CONTEXT:
Human being spend much time observing the world in which they live in. observing the world is something were familiar with is just that we have not considered it as a way of doing formal research. Observation does not just involve vision, it includes interpretation of that same date, it’s not just recording of data from environment we observe, we are active our brains are engaged as well as our eyes and ears. In a social gathering where you don’t know people researcher can adopt participant observation where she has two roles to play that is being an observer and participant. In a hospital a nurse can pretend to be a patient in other to be admitted into the ward to enable her obtain adequate information because informant

CONCEPT 9-DOCUMENTATION IN NURSING.
Documentation is an act of supporting references or records. Nursing documentation has been one of the most important functions of nurses since the time of Florence Nightingale because it serves much purpose. Current health care system requires that documentation ensures continuity of care and must be put into practice. Documentation is proper recording as regards to time, place, circumstances and attribution. It’s a written record of information. Communication is the first important step to documentation because nurses can’t document a patient information and medical history without interacting with them. Even the simplest statement could end up becoming very important when determining a treatment or even diagnosis.

PERSONAL CONTEXT:
Personally I feel documentation is vital in health and nursing practice. Though some nurses see it as a big task but when it is done at the right time it will even make the shift smother. To me is not a big deal because documentation has really saved me a lot of stress and troubles. For example attention of a doctor was needed for a case, I called him severally but his response is always am on my way but he never showed up until patient gave up. I was saved due to proper documentation of everything that happened time, place and all his responses. Nurses need to be up and doing in recording information in other to excel in all aspect of their

For instance if a patient refuse to take his medication nurses document exactly what the patient said in the patient’s own word like nurse I won’t take this drug am tired of it and he threw it on the floor. The nurse in question will document the time, date and her full name including signature to avoid being criticized she will go further to explain how she notified the physician, how she provided the care and also verbal and non-verbal responses of the patient . Good documentation is very important in the care of patient and nursing practice even in advancement of nursing profession.

CUURENT STUDIES:
Documentation has been explained by so many authors and many studies have been done concerning it. According to Kammie Monarch JD,R.N. Documentation can protect nurses against allegation of negligence and malpractice, preservation of medical records and mistakes commonly made in charting that leave nurses vulnerable to law suit. Kathy Graves Ferrell, BS, RN, CLNC. On the other hand said that even nurses who meet standard of care must document that carefully and accurately to avoid vulnerable accusation of malpractice that may result in costly jury verdict and court decision. These two authors are pointing out same issue of how important documentation is and how it can safe medical practitioners like nurses.