Nursing Assignment: Patient Care, Communication, and Documentation

This report delves into crucial aspects of nursing practice, including patient-centered care, communication, and documentation. The assignment explores the importance of patient-centered care, emphasizing dignity, empathy, respect, and autonomy. It also examines verbal and non-verbal communication skills, highlighting the significance of cultural sensitivity and effective interactions with diverse patient populations, including the use of interpreters when necessary. Furthermore, the report discusses the importance of accurate documentation, including electronic and written records, and the role of management information systems (MIS) in healthcare. The report emphasizes the necessity of maintaining updated and organized patient records to ensure cost-efficient care and reduce clinical errors, adhering to organizational policies on record maintenance. This comprehensive analysis provides a strong foundation for understanding and applying these key concepts in nursing practice.

Running head- NURSING ASSIGNMENT
Assessment 1
Name of the Student
Name of the University
Author Note

1NURSING ASSIGNMENT
Reading 1- Patient-centre care
Patient-centred care is imperative to contemporary healthcare services. Traditionally, patients
were viewed as passive receivers of healthcare services, which has been replaced by new
thoughts that consider patients as integral members in the healthcare context. Patients and their
families are therefore considered valuable in ensuring delivery of safe and efficient care services.
The definition is underpinned by several terms such as dignity, empathy respect, autonomy, and
transparency. It focuses on a holistic approach of planning, and evaluating the condition,
followed by fostering a mutually beneficial partnership with the clients and healthcare
professionals. Healthcare professionals are expected to demonstrate and open mindedness and
self-awareness of their roles and responsibilities. They are also responsible for understanding
patient perspective, involving patients during clinical decision making, respecting ethnic and
cultural preferences, delivering transparent information, providing support for self-care services,
and fostering effective communication on probability and risks of a disease.
Reading 2- Verbal and non-verbal communication skills
Verbal communication refers to information exchange that involves use of written and
spoken words. Appropriate use of spoken and written language demonstrates the educational
attainment, intellect, and origin of individuals. However, proficiency in English is not considered
as an indicator of the above factors. Working with drivers CALD clients requires recognition of
the cultural background, which is facilitated by use of an interpreter. Verbal interactions in
healthcare scenario often include giving oral report, formulating care plans and monitoring
progress of a patient.
Non-verbal communication is conducted with the use of appropriate gestures, facial
expressions and body language. It involves use of visual cues, touch, voice modulation and

2NURSING ASSIGNMENT
distance. Maintaining eye contact helps in information exchange by expressing the intended
meaning of particular messages. Therefore, there is a need to gain a sound understanding of
appropriate verbal and nonverbal signs to be used while communicating with culturally and
linguistically diverse clients.
Reading 3- Documentation
Documentation refers to electronic or written generation of legal records, relevant to the
healthcare services being provided. It includes information on the assessment, identification,
planning and implementation of healthcare services for a particular illness. Use of management
information systems (MIS) are gaining their importance allow easy access of clinical database
that facilitates evidence-based nursing. MIS help in better management of patient data, act as
repertoires of legislations, store confidential information and facilitate clinical decision-making.
Patient records refer to written information on the progress of the patient and contain a
compilation of health related information.
Regular monitoring and revision of patient health status are required for delivering cost-
efficient care services. Hence, it is imperative for all healthcare professionals to keep these
records updated and organised. Appropriate patient records help in lowering rates of clinical
errors. It is therefore an essential duty of healthcare professionals to show adherence to the
organisational policies of record maintenance.