Practicum Project Description: Documentation Speed

Improving patient documentation is critical. On a patient-by-patient basis, it can improve individual care, since what cannot be measured cannot be improved in terms of the patient’s overall health baseline. Accurate patient records are also needed to keep track of patients’ past medical history, past and current treatments, and medication history. The American Nursing Association (ANA) views accurate documentation as critical to nursing (2010): “it is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care” (p.3). Documentation protects the healthcare institution from possible legal complications, is a source of feedback regarding what services should receive priority, and consistency in documentation enables the nurse to communicate with other nurses and other providers over the course of the patient’s treatment and care.

Given the ANA’s interest in documentation, communicating the results of the study would be useful on professional websites and blogs in a concise, and easy-to-read format, as well as in more extensive form in peer-reviewed journals. Websites and professional journals are the easiest way to reach nurses, hospital administrators, and others who are seeking out the most technologically advanced yet user-friendly ways to conduct nursing documentation at their workplaces. It is also important to convince providers of the importance of documentation, because nurses are often more interested in improving patient care and regard documentation as an unnecessary hassle (Castledine, 1997). The purpose of this project is to show how the use of new technologies can facilitate the ease of the documentation process, rather than create new hassles as is sometimes feared. Although a learning curve may be inevitable, once the new standard operating procedures become natural, documentation via technology is both more easily disseminated and more easily recorded.

References

ANA’s principles for nursing documentation. (2010). The American Nursing Association (ANA). Retrieved from: https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of- nursing-documentation.pdf

Castledine, G. (1997). The importance of nursing documentation. British Journal of Community Health Nursing, 2(8). 372-372 Retrieved from: https://www.magonlinelibrary.com/doi/abs/10.12968/bjch.1997.2.8.7274