Professional Practice I: Patient Chart Documentation Learning Plan

This assignment is a learning plan focused on patient chart documentation within nursing practice. It includes a self-assessment identifying strengths in areas like caring, documentation, technology, and punctuality, as well as areas for improvement such as team building, prioritizing, and leadership. The learning plan outlines specific goals to enhance leadership skills and improve collaboration for accurate decision-making. Activities are designed to achieve these goals, with methods for evaluating the changes and outcomes in the student's practice. References to relevant research articles support the discussion on nursing documentation frameworks and the importance of caring relationships in nursing care. Desklib provides access to similar assignments and study resources for students.

Running head: PATIENT CHART DOCUMENTATION 1
Patient Chart Documentation
Student’s name
Institutional affiliation

PATIENT CHART DOCUMENTATION 2
Professional Practice I – Learning Plan Assignment – 5%
Patient chart documentation as a nurse
Patient chart documentation is a requisite in healthcare since it contains vital roles and
information of every member. Notably, in nursing, the patient chart documentation assists in
developing the continuity of quality patient’s care, safeguarding the nurses from malpractice,
justifying the clinical reimbursement, and fostering communication between the providers in the
health care. The patient chart documentation in healthcare provides the nurses with a record of the
performances done concerning the patient in the past. The chart mainly includes prescriptions,
procedures, results of the test in the healthcare and all the interactions that the patient has undergone
with health care professionals and doctors. Medical conditions, past surgeries, and hospitalization are
also documented to provide essential information that a nurse may require to understand the
occurrences of the patient and define the problem.
Some of the steps that get included in the patient chart documentation include registration,
development of financial responsibility, check out and check in of the patient, checking for billing as
well as coding compliance. Transmitting and preparing claims, monitoring the adjudication payer,
creating patients bills and statements, assigning payments and arranging collections to the patients
(Blair, & Smith, 2012). Nurses check doctors’ orders from the written request by a doctor or entering
into the patient's chart in the direction of the doctor. However, formal orders get valued for
instructive the allocation of a specialist in a specific setting. Patients are identified either through the
particular record number of outpatient, inpatient or emergency patients.

PATIENT CHART DOCUMENTATION 3
Self- Assessment
Areas of Strength Practice Concept Practice Component
1. As a nurse, i can prepare patient
documentation following the entire
procedure of documenting. According to
a rule in the nursing specialty, I
understand that if I have not recorded the
information, then the whole process is not
prepared. I can ensure that the
documentation provides consistent and
safe quality health care to the patient.
I also have the competence to use the
technology software that is used to
improve health care and mitigate the
diseases among the patients. Am also
competent in using the technology to
handle the billing methods and track the
procedures in the hospital (Blair, & Smith,
2012).
Caring and
competency
Documentation and
technology
2. As a nurse, I understand that a caring
relationship is a vital segment that
facilitates the health and also the process
of healing in a patient by engaging the
specific requirements of the patient. I can
Caring and
connectedness
Caring Relationships

Confidentiality

PATIENT CHART DOCUMENTATION 4
establish a good relationship with the
patients and also maintain it with the
patients to provide a good working
environment for them (Wälivaara,
Sävenstedt, & Axelsson, 2013)..
3. As a nurse, I understand that punctuality is
a significant segment in the nursing work
since there are rotations and change if
shifts among the workers. The variations
ensure that there is no availability of gaps
in the health care. Punctuality is therefore
essential since patients require meeting the
providers at all times and also receiving
perfect treatment (Blair, & Smith, 2012).
Caring and
professionalism
Punctuality
Areas for Improvement
1. Despite the excellent relationship I
establish with patients, I need to improve
on the skills I have on team edifice to
ensure that being able to collaborate with
others and enhance communication to
Caring and healing
and health promotion
Team Building

PATIENT CHART DOCUMENTATION 5
make accurate decisions.
2. Due to challenges in the healthcare of
constraining resources, I need to advance
my skills on the prioritizing methods to
ensure that the needs of the patients are
balanced and costs incorporated when
delivering care.
Caring and practice
judgement
Prioritizing
3. Since leadership is the leading influential
factor in the healthcare organization, I
need to improve my leadership strategies
to ensure that quality health gets provided
(Blair, & Smith, 2012).
Caring and
professionalism
leadership
Learning plan
Student Name:
____________________________________________________Date:_________________________
_________
Name:

PATIENT CHART DOCUMENTATION 6
Learning Needs: What learning needs did I identify through practice reflection and peer input
etc.? Identify a minimum of 2 learning needs.
1.
Leadership skills
2.
Team building strategies
Learning Goal #1 (goal must be based on your learning needs) Practice
Concept:
Acquire Actual leadership of healthcare to help in strengthening integration and quality of care.
Activities and Timeframes How am I going to achieve my goal? Identify a minimum of 3 learning
activities with timeframes for each.
1. Engage in activities that need powerful communication at least for one month in the health care
organization.
2. Involve in methods of relationship development for two weeks to have all the required skills of
supporting the objectives of the organization.
3. Learning skills on how to make a quick decision after evaluating the issues and challenges in the

PATIENT CHART DOCUMENTATION 7
organization (Wälivaara, Sävenstedt, & Axelsson, 2013)..
Evaluation of changes/outcomes to my practice: How can I demonstrate to my teacher that I have
achieved my goal? Identify 3 ways that you can demonstrate you have achieved your goal.
1. Despite the type of individuals involved in the group I have professional and skillful
communication and come into a conclusion.
2. Competent to listen and learn from other people and let them contribute ideas. When able to accept
the mistake and learn on the better methods to perform a task.
3. When bound to face challenges and has a mindset that is flexible and ready to make decisions or
adapt to the new situations (Wälivaara, Sävenstedt, & Axelsson, 2013)..
Learning Goal #2 (goal must be based on your learning needs) Practice Concept:
Ensure that am competent to collaborate with others and enhance communication to make accurate
decisions.
Activities and Timeframes How am I going to achieve my goal? Identify a minimum of 3 learning
activities with timeframes for each.
1. Engage in activities that recognize and assign roles to the members of the team for two weeks.
2. Involve in activities that set the bar of health care which entails measuring and analyzing
objectives to mitigate errors for one week.
3. Engage in activities that entail setting goals of the team on how to have a good outcome at the need
for two weeks.
Evaluation of changes/outcomes to my practice: How can I demonstrate to my teacher that I have
achieved my goal? Identify 3 ways that you can demonstrate you have achieved your goal.

PATIENT CHART DOCUMENTATION 8
1. Having not only technical skills but also emotional knowledge on how to treat others.
2. Can understand others opinions and share common objectives in the team
3. Able to provide proactive communication in the group that entails providing data and support
before being asked (Wälivaara, Sävenstedt, & Axelsson, 2013).

PATIENT CHART DOCUMENTATION 9
References
Blair, W., & Smith, B. (2012). Nursing documentation: frameworks and barriers. Contemporary
nurse, 41(2), 160-168.
Wälivaara, B. M., Sävenstedt, S., & Axelsson, K. (2013). Caring relationships in home-based nursing
care-registered nurses’ experiences. The open nursing journal, 7, 89.