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RUNNING HEAD: NARRATIVE NURSING NOTES1NURSING NARRATIVE NOTES IN ELECTRONIC HEALTH RECORDS: A KEYCOMMUNICATION TOOLStudent nameCourse TitleInstitutional affiliation
NARRATIVE NURSING NOTES2IntroductionQuality professional communication in nursing is essential for desirable patientoutcomes. Understanding the concepts and principles involved is as important as the applicationof the said principles in nursing practice. Nursing documentation is one of these concepts. Innursing, something not documented is considered not done. it is one of the traditions of nursing.It is ever important in this era of patient-centered care.The current paper will critique the following topic that relates to professional nursingcommunication: narrative notes in the electronic health record: a key communication tool. It willoffer a critical analysis of the concepts of electronic health records and the incorporation ofnarrative notes in the electronic records. The strengths and limitations of the concept will bedissected with a view of presenting clear recommendations and implications for nursing practice.The concepts will be discussed with current studies from peer-reviewed journals andpublications.Nursing communication and documentationThe proper documentation of patient status is a skill that nurses use to effectivelycommunicate the health status both current and past and the outcomes of continued care. Propernursing documentation should show the nursing thinking process as decisions behind patient careare done and also provide the evidence of patient progress. Many pathways exist in this regardincluding clinical notes, narrative notes, focus notes and problem-oriented approaches (Blair &Smith, 2012). In the era of patient-centered care and medico-legal issues, nurses too have to beon the right side of the law to avoid litigation. This can be achieved through properdocumentation of the entire patient care process.
NARRATIVE NURSING NOTES3A popular saying in the nursing field holds true; not documented, not done. it is a culturethat has been fostered and has shown to improve patient outcomes and clinical progress. It alsoenhances interdisciplinary communication and flow of information. A good example iscontinuity of care following a handover of shifts (Kossman & Scheidenhelm, 2008).Electronic health recordsA study by Keenan et al. (2012) showed nurses devoted 31 to 37% of their entire shifttime documenting, communicating the information and retrieving it, with 7% of the time spentdocumenting. This is the reason an effective recording system was sought after, and electronichealth records came to be widely used (Clynch & Kellett, 2015).Electronic health records are one of the documentation methods currently beingincorporated into the health sector (Hayrinen, Saranto, & Nykanen, 2008). The transition frompaper-based medical recording to electronic was deemed a step-up in the right direction (Cheunget al., 2013). The electronic health system allowed for entry of patient data into the system thatallowed retrieval and editing of data by different health professionals with access (Hayrinen,Saranto, & Nykanen, 2008). Singapore is one of the countries that has implemented this globaltrend in health recording. It was postulated that reduction in medical errors and enhancingeffective communication through these systems should translate to better patient care.Data in the health record are entered as a structured field with a provision for entry ofnarrative formats. This was implemented to reduce the time taken by clinicians accessing andcharting paper records. Structured data fields in the electronic health record allowed for data tobe entered faster, faster analysis and provided easier access, with menus that can be easilylocated by clinicians. The structured data can also be used for assessment and to guide