Nursing Documentation

Importance of the Issue

Nurse need to keep the records and specific information about their patients. The services in the hospitals require that every detail of the patients be kept in the records. For patients whose conditions recur, record helps the medical practitioners understand the health history of the patient. Proper records in the hospital are helpful in patient transfers (Voyer et al. 2014). Often, patient referrals are common in hospitals and thus records help the doctors in the new hospital to attend to the needs of the patient. The family members of the patients require the health records of their patients to arrange for better treatments. The law requires the nurses to keep records of the nature of services they offer to the patients. Often, the records of each patient are permanents in the hospital where they are kept physically or electronically. Records are essential because they indicate whether the patients received the services and their health history is tracked. The nurses use the records to attend to the patients and their needs. For example, in some hospitals, the populations of patients are high; records help the nurses identify the patient and the medical care they need.

Ideally, the record proves that the nurse understands what she needs to do and honors her duty. The record is helpful to the nurses because it contains the procedures of how to attend to the patients. In this case, it directs the activities of the nurse and prevents omissions of some important activities that may compromise the health of the patients (Voyer et al. 2014). Often, the records help the nurses to track the progress of their patients and the nature of service they need to better their health conditions.

How Does Documentation Affect Nurse Practice?

The nurse council requiring them to adhere to the rules and regulations provided by the body governs the work of a nurse. As a result, documentation is one of the practices that help nurses perform their duties in a better way. First, documentations define a trained nurse from other professions. Ideally, transfer of nurses from one health care to another is common. In such a case, the records help the nurse continue with healthcare of the patients. Documentation helps the nurse plan their day. For example, during the day, the activities are many; the nurses need the records to know what has happened and what to do. Nurses operate promptly in the healthcare settings when all the records of the patients are available on demand. Nurses take turns during the day and thus records helps the nurses to take turns swiftly in their workplaces. Documentation is an act of professionalism for the nurses. Record keeping is important in the case of a legal challenge involving a health facility....
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For example, in a situation where patients appeal for lack of quality care, the nurses use the documentation to defend their actions. Nurses use the records to advise the family members on the next step to take if the medical condition of the patient persists

How Documentation Changes My Practice

Improving record keeping translate to the improvement in the service provision for the patients. Adapting the right practices for the health records helps reduce the chance of errors resulting misuse of the information. For example, sing different information to provide health care to the patients is risky. As a result, using the right information to attend to the patients reduce the common mistakes of confusing the records. As a nurse, keeping good records show professionalism and compliance to the nursing ethics.

Notably, learning to keep records of the patients is a source of motivations because the nurse uses the records to monitor improvements in the health of the patient. The recording keeping is an act of professionalism for the nurse (Voyer et al. 2014). The body governing the nursing practices requires the nurses to keep a sound record to ensure the safety of the patients. The nurse uses the patient record to defend themselves from the lawsuits in case the patient appeal for a case in the court. The record makes work easier for nurses because they can easily trace patients and their locations.

Limited Nurse Staff

Importance of the Issue

The ratio of patient to nurse should be favorable to reduce the chance of fatigue. The number of staff in the health care matters considering the amount of work. It is important to know the number of staff to understand how to allocate duties and the amount of workload for every employee. The amount of work in the health care depends on the number of personnel and the number of patients seeking for the medical attentions in the facility. Often, the remunerations for nurses reflect the amount of task in the healthcare (Lartey et al. 2016). For this reason, knowing that the number of nurses is limited lay the foundations for bargaining. The managers should be able to approximate the amount of work that one does in one day. The knowledge of the number of the nurse in the health facility helps to give a clear picture the expectations of from the workplace.

How Does Limited Nurse Staff Affect Nursing Practice?

Ethics and professional guidelines govern nursing practice. Every nurse governs by rules and thus the need to comply. Notably, nurses are licensed to practice as a nurse and the activities of the nurse should comply with laws. However, the limited nurse staff regulates the number of patients to admit. Often, hospitals admit the patients that the…