When I was still working at the bedside and would orient nurses I was a stickler about documentation. Individual insurance can also keep nurses from losing their assets in the unlikely but possible event of a huge judgment against them.
They include built-in edits to ensure correct recording of dosages by comparing nurse entries with the issuing pharmacy instructions and the original scripts. Order the digital download if you cannot join us that night. For patients to make informed decisions, there must be accurate information available for them to review.
Most of the others were against nurse anesthetists, nurse midwives, and nurse practitioners. Behavioral Health Services Across the street at Mental Health Center A, a state department of health surveyor identified Nurse A repeatedly documenting the same text on progress notes completed for several patients on her caseload.
Items I found challenging: Digging through his notes to figure out what would be the appropriate next step in his management.
What are some examples of this practice in electronic environments that is a fully legitimate and desirable method for documentation? Training Requirements Annual education and training: The physician order entry software provides the capability for default self-selection upon entering the first three letters of the drug.
Health interventions also follow a standard course. In Japan, the average physician visit is between 3. All other notes should reflect care and treatment to support the acute on chronic systolic congestive heart failure.
Both of these dates are important to best practices in HIM. She has a number of chronic health problems, takes a number of medications, and has an allergy to drugs containing quinolone. Poor Documentation Defined Before tackling a documentation problem, health care organizations must elucidate whether indeed there is a problem in the first place.
Mertz's physician is asked by the EHR system to verify selection of Norfloxacin because the current medication history indicates that the patient had an anaphylactic reaction to another antibacterial agent that includes quinolone.
EHRs that lack adequate audit trail functionality create uncertainty in the integrity of health record documentation, and may create legal liability for the organization while inadvertently making or protecting criminal activity.
The patient with dementia presents to the clinic with a nursing assistant from Nursing Care Facility A, she is registered as Ethel Mertz, and her health records are placed in queue for Dr. The biggest reasons for lawsuits against nurses include medication errors; communication errors; failure to monitor and assess; failure to properly advocate for the patient; working while impaired, whether by inadequate sleep or controlled substances; and negligent or inappropriate delegation and supervision, say nurse legal experts interviewed for this story.
This alarmed the clinician, as he prescribed the medication that the patient had indicated a possible reaction to in the past.
A special feature of the software ensures optimal reimbursement for skilled beds through a point-of-care system that prompts nursing personnel to enter data elements. Nurse A used this shortcut for documentation as one way to get her charting completed in the EHR before the end of her shift.
After you have completed an activity, return to this page to proceed to the next activity. The consequences of poor documentation all come full circle.
In reviewing the chart first of all I found that there was no documentation that this was done every 2 hours; secondly most of the time the part of the exam involving the pupils was not even addressed and if it was they did not always mark the size of the pupils.The quality of nursing documentation is an important issue for both patients and nurses.
Obviously quality nursing documentation enhances patient care. The way in which poor performance in nursing and midwifery is managed is of concern to individual practitioners, managers, employing organizations and to patients. the decision and documentation is poor.
The evidence also suggests that clinicians who report poor process in nursing: a case study approach. Work Employment -The Management. J.R.
Henry Consulting Inc. dominicgaudious.net () 3 EMS DOCUMENTATION Case Studies, Compliance and More! Superior Court - June 28, Scenario 1. P.W. is a year-old female with a history of upper GI bleed, indeterminate pulmonary nodules, and more recently decreasing functionality at home involving muscle weakness and hand swelling, who presents today for follow-up of her hand swelling and urinary incontinence.
literature reveals and presents six case studies which show that there is growing importance of interprofessional education and collaborative practice as a means of strengthening health care provision. Case Study 1 Issue: Electronic Tools That Enable Borrowing Data from Another Source.
Electronic tools make it easy to copy and paste documentation from one record to another or pull information forward from a previous visit, someone else's records, or other sources.Download