Narrative nursing Notes Assignment
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Added on 2021-05-31
Narrative nursing Notes Assignment
Added on 2021-05-31
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RUNNING HEAD: NARRATIVE NURSING NOTES 1NURSING NARRATIVE NOTES IN ELECTRONIC HEALTH RECORDS: A KEYCOMMUNICATION TOOLStudent nameCourse TitleInstitutional affiliation
NARRATIVE NURSING NOTES 2IntroductionQuality professional communication in nursing is essential for desirable patient outcomes. Understanding the concepts and principles involved is as important as the application of the said principles in nursing practice. Nursing documentation is one of these concepts. In nursing, 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 nursing communication: narrative notes in the electronic health record: a key communication tool. It will offer a critical analysis of the concepts of electronic health records and the incorporation of narrative notes in the electronic records. The strengths and limitations of the concept will be dissected with a view of presenting clear recommendations and implications for nursing practice.The concepts will be discussed with current studies from peer-reviewed journals and publications.Nursing communication and documentationThe proper documentation of patient status is a skill that nurses use to effectively communicate the health status both current and past and the outcomes of continued care. Proper nursing 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 regard including 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 be on the right side of the law to avoid litigation. This can be achieved through proper documentation of the entire patient care process.
NARRATIVE NURSING NOTES 3A popular saying in the nursing field holds true; not documented, not done. it is a culture that has been fostered and has shown to improve patient outcomes and clinical progress. It also enhances interdisciplinary communication and flow of information. A good example is continuity 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 shift time documenting, communicating the information and retrieving it, with 7% of the time spent documenting. This is the reason an effective recording system was sought after, and electronic health records came to be widely used (Clynch & Kellett, 2015).Electronic health records are one of the documentation methods currently being incorporated into the health sector (Hayrinen, Saranto, & Nykanen, 2008). The transition from paper-based medical recording to electronic was deemed a step-up in the right direction (Cheung et al., 2013). The electronic health system allowed for entry of patient data into the system that allowed 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 global trend in health recording. It was postulated that reduction in medical errors and enhancing effective 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 of narrative formats. This was implemented to reduce the time taken by clinicians accessing and charting paper records. Structured data fields in the electronic health record allowed for data to be entered faster, faster analysis and provided easier access, with menus that can be easily located by clinicians. The structured data can also be used for assessment and to guide
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