Reflection on documentation
REFLECTION ON DOCUMENTATION ASSESSMENT EXPERIENCE
I have come to learn that documentation is an important part of nursing practice, in the clinical setting (Perry & Potter, 2014). One of the fundamental aims for nurses in all areas is to safeguard the welfare of their patients through proper documentation ((Nursing and Midwifery Board of Australia - Codes and Guidelines, n.d). This can be achieved by implementing and upholding good documentation practice through progress notes writing in every healthcare department specifically nursing (Miller & Cameron, 2011). In this briefing essay am going to provide an insight into the benefits of proper documentation in nursing and I will highlight the areas in need of development when writing my progress notes.
The quality of care a patient receives relies heavily on appropriate and correct communication through documentation (Patient Progress Note & Dictation Standard, n.d.). I have learnt to document information that is specific to the patient through avoiding generalising statements like “observations between the flags” instead; I should document information that is specific to the patient. Hence, am continuing to practice proper documentation particularly by providing clear records which will allow other health care professionals to provide accurate and timely care for the patient hence avoiding miscommunications (Nursing and Midwifery Board of Australia - Codes and Guidelines, n.d).
I have also learnt to implement appropriate and effective procedures when documenting through following Information, Situation, Background, Assessment, Recommendation (ISBAR) in a comprehensive mode (Nursing and Midwifery Board of Australia - Codes and Guidelines, n.d.). ISBAR provides a systematic structure in rendering professional and quality nursing care and also the integral part of the nursing practice. Thus, I am still learning to document with utmost attention and practice in the clinical setting (Nursing and Midwifery Board of
I have come to learn that documentation is an important part of nursing practice, in the clinical setting (Perry & Potter, 2014). One of the fundamental aims for nurses in all areas is to safeguard the welfare of their patients through proper documentation ((Nursing and Midwifery Board of Australia - Codes and Guidelines, n.d). This can be achieved by implementing and upholding good documentation practice through progress notes writing in every healthcare department specifically nursing (Miller & Cameron, 2011). In this briefing essay am going to provide an insight into the benefits of proper documentation in nursing and I will highlight the areas in need of development when writing my progress notes.
The quality of care a patient receives relies heavily on appropriate and correct communication through documentation (Patient Progress Note & Dictation Standard, n.d.). I have learnt to document information that is specific to the patient through avoiding generalising statements like “observations between the flags” instead; I should document information that is specific to the patient. Hence, am continuing to practice proper documentation particularly by providing clear records which will allow other health care professionals to provide accurate and timely care for the patient hence avoiding miscommunications (Nursing and Midwifery Board of Australia - Codes and Guidelines, n.d).
I have also learnt to implement appropriate and effective procedures when documenting through following Information, Situation, Background, Assessment, Recommendation (ISBAR) in a comprehensive mode (Nursing and Midwifery Board of Australia - Codes and Guidelines, n.d.). ISBAR provides a systematic structure in rendering professional and quality nursing care and also the integral part of the nursing practice. Thus, I am still learning to document with utmost attention and practice in the clinical setting (Nursing and Midwifery Board of
References: Carpenito, L. J. (2009). Nursing care plans & documentation: Nursing diagnoses and collaborative problems. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Lippincott Williams & Wilkins. (2011). Chart Smart: The A-to-Z guide to better nursing documentation. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Nursing and Midwifery Board of Australia - Codes and Guidelines. (n.d.). Retrieved May 17, 2015, from http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx#competencystandard Perry, A. G., Potter, P. A., & Ostendorf, W. (2014). Clinical nursing skills & techniques. St. Louis, MO: Mosby/Elsevier. Patient Progress Note & Dictation Standard. (n.d.). Retrieved May 17, 2015, from http://bphc.hrsa.gov/archive/technicalassistance/resourcecenter/services/patientprogressnoteprotocol.pdf WACHS Allied Health Assistant Training Mini-Module Documentation. (n.d.). Retrieved May 17, 2015, from http://www.wacountry.health.wa.gov.au/fileadmin/sections/allied_health/WACHS_G_AHA_TrainingMini-Module.pdf