Departmental managers and staff from laboratory, radiology, cardiopulmonary and nursing participated as committee members. The committee members reviewed Joint Commission National Patient Safety Goal 2 safety reports (2010), scrutinized communication processes and additional patient charts were audited for critical lab value documentation. The committee members discovered a breakdown at the point of documentation in the read back procedure. The read back procedure was being carried out, however the nurses had difficulty in consistently documenting when a report was received due to lack of computer…
When the patient is called back to their examining room, the medical assistant will ask for the reason for the visit. It is up to medical assistant to write down the signs and symptoms of the patient. The documentation must be detailed and recorded properly on the patients face sheet. The department manager of nurses should be scrubbing the documentation before it is submitted to the billing department. For example, if a patient has a routine check and the physician decides to order labs, the lab draw must be documented; even though it was not the…
Nurses need to be effective with their critical thinking skills and utilize the resources at hand. Using base knowledge to prevent catastrophic events from occurring, such as the potentiation effect of medication. Knowing ,when we as nurses, have met our ability to perform effectively and need assistance is not only important for our well being but the well being of the patient and the organization as a whole. Integrating teamwork in the patient care effort not only builds a solid foundation for the organization but also for the positive outcome of the patient being treated. If for some unfortunate reason an adverse event does occur nurses must remember they “provide valuable insights into care processes when working with patient safety leaders as part of a root cause analysis team. Nurses ' unique knowledge of the care provided is essential for designing the best improvements in care processes” (Hall, Moore, & Barnsteiner, 2008). Probably among the most import ways a nurse can improve quality of care is his/her own self care. This can be done in many ways. Meditation for stress reduction, continuing education for confidence in patient care, are just a few examples. Having a rested, positive, confident attitude when preparing and performing patient care can make difference and help her do no harm and give the utmost quality of care to each patient she/he comes in contact…
Dimmond, B. (2005) Exploring the principles of good record keeping in nursing British Journal of Nursing Vol 14 (8) p460-462…
In these cases, charting was a very important part of the care provided by her. Per her, improper charting and incompetent care could have potentially led to legal ramifications for her and the institution. She also addressed some of the ethical issues by stating that in her practice, she made sure that she didn’t release the patient information to the party that was not directly involved in that patient’s care.…
When a nurse is hired to work in a facility they are expected to follow various policies and procedures set forth by the facility and to abide by practice regulations set forth by the governing body that issued their nursing license. Nurses can utilize nursing-sensitive indicators in their daily practice to promote safe and quality care to their patients, resulting in positive outcomes.…
It's very important to always double check your work, You should make it a habit, so you don't make any mistakes. Always make sure you fill out paper work right the first time, Each person who enters information in a medical chart must make sure the notations are mistake-free, complete and tell a story. Any missing, or excessive, detail can affect charges on a final bill and determine how much is covered by insurance. A patient should never get charged if a physician makes the mistake, and always be careful with double billing you don't want to get billed twice. Any errors that happen can get lost or delayed. Listen and correct any information that's needed. You don't want to put in the wrong codes. The wrong date or code can be as simple as…
In every profession there are changes that propel how tasks are done; nursing is no stranger to this. One of the biggest changes that have come into nursing’s daily events is how report hand-offs are being done. Gone are the days of taped report that each off going nurse must tape about each patient and the oncoming nurse must listen to. Nurses are now being encouraged to move their report to the bedside, in front of the patient (Trossman, 2007). It is very important to know how this can affect the patient and even the nurse’s schedule. With every change, there are positives and negatives that can finalize the decision to keep or forego the change.…
Collection, analyzing, and interpretation of data are important functions at the skilled facility. The nurses are major contributors of data that is either, generated electronically or by the health record department staff. Health care provision today is centered on evidence-based care, which continues to influence the type of care patients receive. Statistical information enables the health care providers to plan, formulate current and future policies, improve patient care through evidence-based studies, evaluate, and improve on customer care, and for compliance purposes. Examples of data collected on daily basis are the daily patient census that summarizes the total number of patients per unit by the end of the day computed manually at 12 midnight. This reporting tool is presented in tabular format and shows all new admissions, readmissions, in-house transfers, transfers out to other levels of care, discharges, deaths, or missing patients. Another example of statistical…
After learning what the patient has arrived for, the nurse must start gathering data that relates to the patient’s chief complaint. For example, if the patient presents with shortness of breath, it is important to gather data such as: oxygen saturation, respiratory rate and effort, lung auscultation, presence of cough, and observing patient color. In…
Bibliography: Bailey, M., Crossen, S., Holland, J., & Hollis, V. (2008) Observation 's in Dougherty, L & Lister, S. (eds) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 7th ed. Chapter 25, Pages 496-544. Oxford: Wiley-Blackwell Publishing.…
I also agree with the idea that staff education and support is highly important because it gives staff comfort to know that it is okay to report an error that may have occurred. Investigating events that may have effected patient status is also another beneficial factor that creates a plateau for staff to grow from. As…
Note that during all phases of the nursing process, meticulous documentation of the information gathered, the diagnoses and plans formulated, the plans implemented, and the findings of evaluations must take place to reflect continuity of care.…
The first chapter that I highly enjoyed reading about was chapter six, Ethical and Legal Issues. Nurses should be aware of the Ethics and Legal issues when dealing with patients at the hospital because if a certain scenario comes up, then the nurse will have to address and figure out the solution. The issue that stood out the most was Confidentiality. Every patient’s information, like medical records, needs to be kept confident within team members. Patients have the option to communicate to the nurses who can see their medical records and the nurses have to abide by the patient’s decision. I cannot stress enough how important it is that nurses keep the patient’s medical information confident and do not communicate to anyone about the patient’s medical…
Article: Carroll, J. (2002). Play Therapy: the children’s views, Child and Family Social Work, 7, pg 177-187…