Nursing Documentation And Electronic Health Record

Running Head: NURSING DOCUMENTATION
NURSING DOCUMENTATION
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NURSING DOCUMENTATION 2
Introduction
Nursing documentation is the recording of nursing care given to patients by competent
healthcare givers under the authority of a qualified nurse. Nursing documentation can be done
manually or by the use of electronic health record. An electronic health record is a certification
tool that produces data useful in promoting the safety of patients, in the evaluation of the quality
of care given, exploiting efficacy, and determining enrollment desires. In this paper, I will
discuss the responsibilities of nurses in the documentation of information, the communication of
graduate nurses with the healthcare team, clinical problems, keeping of medical records,
medication records, identification of the other areas that as a graduate nurse, I can assist and
categorizing my views to enhance computer vocabulary of nurses and contributing in the view of
nurses to make their grievances voiced out to the IT staff and vendors and to take place when
nursing-related IT concerns are tabled.
Personal and professional self-reflection
Patient documentation is, in most cases utilized by experts who are not directly involved
in the care of patients. As a nurse, I will do patient documentation which is timely, accurate and
accessible, complete, readable and in good standards (O'Brien, Weaver, Hook, & Ivory, 2015).
Failure to observe the latter will interfere with the ability of the personnel not involved in and
who are not familiar with the patient care to make use of the documents. The most inter-
professional use of nursing documentation includes;

NURSING DOCUMENTATION 3
Credentialing
Nursing documentation that I will keep will serve in monitoring the performance of the
healthcare practitioners and the compliance of the healthcare facilities with the standards that
govern the healthcare facility and the provision of healthcare. The documentation is vital in the
determination of which credentials will be granted to the healthcare practitioners in an
organization
Legal
I will take the responsibility of giving clinical reports of the patients, provider’s
documentation, administrators’ records and documents related to the patients and organizations
that provide support to the patients and the organization. I will ensure that I keep complete,
timely, and accessible documentation. Any documentation that is not complete, untimely,
illegible and inaccessible can lead to undesirable outcomes including;
Legal fact-finding
Jeopardize legal rights
Patient healthcare organizations and providers at risk of liability (Akhu‐Zaheya, Al‐Maaitah, &
Bany Hani, 2018)
Reimbursement
I will keep comprehensive documentation that will be used in the determination of the
severity of illness and in the decision of the quality of care provided upon which payment or
reimbursement of healthcare services is based. Comprehensive documentation is important since
it offers information about the characteristics of care outcomes. Assessment and examination of
documentation data are fundamental for accomplishing the objectives of evidence-based practice
in nursing and healthcare services. Comprehensive documentation is the essential wellspring of

NURSING DOCUMENTATION 4
proof used to persistently measure execution results against foreordained gauges, of singular
medical caretakers, social insurance colleagues, gatherings of medicinal services suppliers. This
data can be utilized to investigate fluctuation from built-up rules furthermore, gauge and improve
procedures and execution identified with understanding care (Lindo, Stennett, Stephenson‐
Wilson, Barrett, Bunnaman, & Anderson‐Johnson, 2016).
All medical attendants must have solid proof-based information on the effect of the
consideration they give on the results that patients experience and information on the nursing-
sensitive measures. The data from such scientific exercises illuminate quality improvement
exercises and assessments of organizational adequacy. Nurses must be given far-reaching
instruction and preparing in the specialized components of documentation and the association's
strategies and methods that are identified with documentation (Lindo, Stennett, Stephenson‐
Wilson, Barrett, Bunnaman, & Anderson‐Johnson, 2016). These instructions and preparations
ought to incorporate shortages on the help that take into account the time required for
documentation work to guarantee that each nurse is fit for:
• Functional utilization of the worldwide documentation framework
• Competence in the usage of the PC and its supporting equipment
• Proficiency in the usage of the product frameworks in which documentation or another
significant patient, nursing and human services reports, archives, and information are caught.
A nurse is supposed to familiarize herself or himself with each strategy and techniques
identified with documentation and apply these as a component of nursing practice (Nomura,
Silva, & Almeida, 2016). Of specific significance are those approaches or systems on keeping up
effectiveness in the utilization of the "personal time" framework for documentation when the
accessible electronic frameworks do not work.