Documentation of Patient Information and Medication Safety in Nursing Practice

Running head: NURSING
Nursing
Name of the Student
Name of the University
Author Note

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Introduction
In nursing, the process of documentation is defined as a comprehensive, sequential
and factual record of the patient’s health related condition, treatment plan and the support
offered. Failure in proper documentation in the patient’s data or clinical history or the therapy
plan might lead to fatal outcomes (Blair & Smith, 2012). Medication errors are a problem in
Australia. Medication errors occur for a number of reasons like human errors and other
factors like how the medicines are prescribed, dispensed or administered to the patient. The
majority of the medication errors in Australia occur as a result of error in the documentation
process leading to increase in the mortality and morbidity of the patients (ACSQHC, 2017).
In order to improve the healthcare outcomes by decreasing the morbidity and
mortality in healthcare, the Australian Commission on Safety and Quality in Health Care
(ACSQHC) has introduced National Safety and Quality Health Service Standards (NSQHS)
in 2012. The standard 4 of the NSQHS outlines the medication safety standard to decrease
the occurrence of medication incidents, and to improve the safety quotient in health and
quality of medicine use (ACSQHC, National Safety and Quality Health Service Standards,
2012). The aim of this review is to examine the role of the documentation of the patient’s
information in the domain of medication safety under clinical practice. At the end the review
will highlight the main implications of the clinical practice. The overall review will be
conducted based on the available literature on that coincides with the scope of this review.
Background
The quality of documentation of the patient’s information is an important issue for
nursing professionals working nationally and internationally (Blair & Smith, 2012). The
documentation of the patient’s information by the clinical workforce deals with accurate

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documentation of the medication history during the process of the patient’s prognosis. It also
encompass documenting the previous patient’s history in relation to the adverse drug
reactions and reviewing the current medication orders against the medication history and
highlighting any discrepancy in the medication plan (ACSQHC, National Safety and Quality
Health Service Standards, 2012). Nursing documentation must, but frequently fail to
highlight critical thinking and rational behind the clinical decision making and interventions
while submitting the written documentation of patient’s prognosis. The gap in the critical
thinking and lack of evidence-based practice leads to improper documentation of the patient’s
health-related information and thereby endangering the concept of the medication safety
(Blair & Smith, 2012). Apart from the lack of critical thinking and problem solving skills, the
increase in the work-pressure or poor nurse : patient ratio in the high-tension ward like the
emergency department or in the ICU leads to the error in the process of the nursing
documentation and creating a barrier in comprehensive implementation of the medication
safety procedure (Hall, Johnson, Watt, Tsipa, & O’Connor, 2016). Thus in order to improve
the medication safety the healthcare industry of Australian healthcare system is spending
surpasses for the adoption of the health information technology (HIT) for proper
documentation of the patient’s information (Schoen, et al., 2012). HIT products like
electronic health records (EHR) and computerised physicians’ based order entry (CPOE)
have now become more intimately involved in delivering comprehensive care by ensuring
medication safety (Lainer, Mann, & Sönnichsen, 2013).
Review of literature
Numerous studies were analysed as part of conducting the literature review. All
authentic yet relevant findings were then classified under three different themes which
evolved as the significant outcome of the review. These three themes include nursing

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documentation by the use of Healthcare Information Technology, Use of COPE in ensuring
patients’ medication safety and privacy and confidentiality issue associated with
documentation of patients information in IHT medium.
Nursing Documentation by the use of Health Information Technology
There is a prolong debate regarding whether the application of the health information
technology is helpful in improving the process of medication safety by increasing the quality
of documentation of the patient’s information. A systematic review was conducted over
randomised control trials by two-reviewers in order to study the effectiveness of information
technology (IT) in ensuring medication safety in the primary care. 5 out of the 10 articles in
the review highlighted that the incorporation of the IT for the documentation of the patients’
information helps in to reduce the chances of the medication errors. Three out of the 10
articles showed that the documentation of the patient’s information through COPE with CDS
(clinical decision support system) was found to be effective for ensuring medication safety
only if targeted at a restricted number of the clinically improper medications or unsafe
prescribing in pregnancy. However, the review highlighted on potential reduction in the
adverse drug effects under the application of the IT-based approach for the documentation of
the patient’s information. At the end, the review stressed about the requirement of the
rigorous evaluation of the large-scale implementation of the IT in order to evaluate the
importance of the nursing documentation in medication safety (Lainer, Mann, & Sönnichsen,
2013). In relation to documentation of the patient’s information and to ensure medication
safety, a focus group interview was conducted over the 21-registered nursing professionals.
The analysis of the survey results highlighted that nurses electronic health records is widely
used by the nursing professionals as the principal method for the nursing documentation
process for ensuring medication safety. However, nurses reported that electronic patient’s
record fails to support nursing practice while documenting important health-related