Reflective Essay On Documentation

Reflection on documentation
Description
There are occasion that patient documentation were not accurate as demanded by a professional nurse and it has been highlight is part of learning needs to improve upon. I have also noticed some errors in writing in terms of the grammatical errors.

Feelings
I unease if the information obtained is not document the way that is received and that make me feel the care given has meet its objective. At the end of a shift I need to assess my self whether the goal setting is achievable and the only is look at my documentation and contemporary notes. I felt poor proper documentation may be difficult for teamwork to progress hence meeting holistic care of the patient

Evaluation of experience
I would say English
is not my first language and some is difficult to some sentences and words meaningful however I have been managing to write as accurate as possible
I would say sometimes when I am under pressure of work load it influence my writing and documentation at the right time and in a good frame of mind
Also, it sometimes depends on the nature of the incident or the nature of information needed to be documented
Also, the nature of the information received as a second-hand information makes it difficult to present it a manner that reflect the actual presentation
Critical Analysis
I have come looked at my documentation progress and it appeared to have lack some coherence and consistency in writing. On the other some of the information’s documented needs to be clear, concise and eligible for others to read it for continuity of care. The meaningfulness of the conversation documented is also of priority because it is asserted that communication to others or two way of communication should be able to receive and give a feedback and that shows that communication has fulfil its purpose. In terms of nursing documentation is quite crucial because of court of law and the ethical reason is providing care of the patient makes you the accountable and liable for your own action. Because of the nature of reporting incidents with patients and staff, one need to ensure whatever information and progress of the patient needs to be document as accurate and precise. More also telephone and emails information causes a lot of problems and one must be careful of what information that is pass on to other department because once delivered is hardly to retrieve and delete because of the internet data base system that is very complex to ascertain.
Conclusion
In summary, I would say documentation is the best form of communication for continuity of care. In addition to that proper documentation avoid unnecessary legal and ethical issues against the nurse and it makes capable of justify their action in terms of accountability
Action Plan
I would know the progress of my document through consistent writing of progress not and hand over notes
I read others notes and gain professional writing experience
Read some communication literatures both books and using the internet
I can role model my mentors to see how they document information
I will gain knowledge from other qualify staff and ask them the strategies used in communication
I should be able to answer phone calls on the ward and present them as accurately as received.
Communicates with staff, patients, family members and other professional and document as appropriate as possible.

Spinner
Reflection on documentation
Description

There are occasion that patient documentation were not accurate as demanded by a professional nurse and it has been highlight as part of learning needs to improve upon. I have also noticed some errors in writing in conditions of grammatical errors.

Feelings
I am unease if the information obtained is not document the way that is received and that make me feel the care given has not meet its objective. At the end of a shift I need to evaluate myself whether the goal setting is achievable and the only way is to look at my documentation or care notes. I felt poor documentation may be difficult for teamwork to progress hence meeting holistic care of the patient

Evaluation of experience
I would say English is not my first language and as such is difficult to construct some sentences and words which are meaningful. I have been managing to write as accurate as possible as it can be
I would say sometimes when I am under pressure of work load it influence my writing and documentation at
mindset
Also, it sometimes depends upon the nature of the incident or the nature of information needed to be documented
Also, the nature of the information received as a second-hand information makes it difficult to present in a manner that reflect the actual presentation
Critical Analysis
I have looked at my documentation progress and it appeared to have lack some coherence and consistency in writing.
On the other some of the information's documented needs to be clear, concise and eligible for others to read it for continuity of care. It is asserted that two way of communication should be able to receive and give a feedback and that shows that communication has fulfil its purpose. In conditions of nursing documentation is quite crucial because of court of law and the ethical reason in providing care of the patient makes the nurse accountable and liable for their own action. incidents with patients and staff, one need to ensure whatever I incident information about patient must be document as accurate and precise. More also telephone and email information causes a lot of problems and one must be careful of what information that is pass on to other department because once delivered is hardly to retrieve or delete it because the internet data base system is very complex to
ascertain.
Conclusion
In summary, I would say documentation is the best form of communication for continuity of care. In addition to that proper documentation avoid unnecessary legal and ethical issues against the nurse and it makes capable of justify their action Action Plan
I would know the progress of my documentation through constant writing of progress notes and hand over notes
I will read others notes and gain professional writing experience
Read some communication literature books and {using the internet.
I can role model my mentors to see how they document information
I will gain knowledge from other qualify staff and ask them the strategies used in communication
I should be able to answer telephone calls on the ward and present them as accurately as received.
Communicates with staff, patients, family members and other professional and document as appropriate as possible.