Nursing Documentation Essay

Errors in Nursing Documentation

Introduction

Nursing documentation forms an integral part of the professional nursing practice. In the last few decades, the nursing profession has witnessed a change in the way documentation should be handled with countries all over the world adopting more sophisticated record-keeping systems. New systems have been designed, old ones re-evaluated and the nurses’ level of compliance with the legal framework monitored. Home health care involves a variety of healthcare services that are administered at home for ill or injured patients. In developed countries, home care is just as efficient as the care received in a skilled nursing facility, and it is relatively cheaper. Home, health care professionals, offer services such as wound care, patient education, therapy whether intravenous or nutritional, administer injections according to the treatment plan and monitor the progress of seriously ill and unstable patients. As home health care professionals, we ensure our patients get better, ensure they become more dependent and self-sufficient.

Documentation in the nursing profession

Research in the area has been emphasized since documentation is an area of priority and forms an integral part of nursing practice. Most of the past studies have however been carried in a hospital setting. The few studies that focused on community health explored the overall comprehensiveness of nursing documentation in a home health care. According to Gjevjon & Helleso (2010), more studies need to be directed towards documentation errors in community settings since home-based care differs significantly from facility-based nursing. Previous research was conducted using paper-based medical records, but currently, most of the home health based patients are now electronic (Wang, Björvell, Hailey & Yu,