Evaluating Healthcare Documentation- Adherence to Standards and Best Practices

Evaluating Healthcare Documentation- Adherence to Standards and Best Practices

Documentation Critique

Nursing documentation is essential for successful medical communication among healthcare professionals. Proper documentation concisely depicts nurse evaluations, variations in medical status, care provided, and essential patient information that assists healthcare workers in providing quality care. Documentation facilitates care evidence and is a critical clinical legal obligation and profession in nursing practice (Julio, 2009). Ms Amy Jones was brought to the hospital after being suspected of having a psychological disorder, and she was treated for sadness and anxiety. Because other medical practitioners were unaware of Ms Jones’ past condition, it is clear that the recording of this patient in the hospital was inadequate. Nurse Hoffman, for example, was not notified that the patient had a headache or had fainted before vomiting. The nurse was also not notified that Ms Jones was sleepy following the hospital incident.

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Documentation of all the patient’s impending and present problems during therapy is required for good documentation data. However, vital signs and symptoms were not documented during Ms Jones’ treatment, indicating the negligence of the patient’s healthcare personnel. Dr Smith and Nurse Sullivan were utterly unaware of the patient’s look following the vomiting session because she was asleep in her wheelchair. Due to insufficient documentation procedures in their healthcare facility, the practitioners did not have a correct diagnosis of the patient’s condition (Tajabadi et al., 2020). Dr Smith, for example, ordered the treatment of Phenergan IM to treat the vomiting sign without knowing the actual underlying cause, demonstrating keen quality care to the patient’s health.

The patient was reported to have poor bowel control, and the medical personnel just bathed Ms Jones and placed her back on the bed. Dr Allen assumed she had a gastrointestinal problem due to poor documentation in the healthcare institution. Ms Jones, on the other hand, would have most likely been diagnosed with the disease that was preventing enough oxygen from entering her brain if the correct paperwork had been produced (Muinga ae al., 2021). For example, it is claimed that the patient had varying eye pupil sizes before being transferred to another hospital. It is an emergency indicator of a significant stroke condition. However, the medical personnel only checked her vital signs and determined that she was all right. Ms Jones, possibly suffering from a stroke, died due to the healthcare provider’s negligence. She was nauseous and lethargic, had an uncontrollable bowel movement, and had unequal pupil size. Those are atypical stroke symptoms that healthcare providers would have noticed sooner to provide the most suitable medical measures.

Nursing documentation is essential for successful medical communication among healthcare professionals. Proper documentation concisely depicts nurse evaluations, variations in medical status, care provided, and essential patient information that assists healthcare workers in providing quality care. Documentation facilitates care evidence and is a critical clinical legal obligation and profession in nursing practice (Julio, 2009). Ms Amy Jones was brought to the hospital after being suspected of having a psychological disorder, and she was treated for sadness and anxiety. Because other medical practitioners were unaware of Ms Jones’ past condition, it is clear that the recording of this patient in the hospital was inadequate. Nurse Hoffman, for example, was not notified that the patient had a headache or had fainted before vomiting. The nurse was also not notified that Ms Jones was sleepy following the hospital incident.

Documentation of all the patient’s impending and present problems during therapy is required for good documentation data. However, vital signs and symptoms were not documented during Ms Jones’ treatment, indicating the negligence of the patient’s healthcare personnel. Dr Smith and Nurse Sullivan were utterly unaware of the patient’s look following the vomiting session because she was asleep in her wheelchair. Due to insufficient documentation procedures in their healthcare facility, the practitioners did not have a correct diagnosis of the patient’s condition (Tajabadi et al., 2020). Dr Smith, for example, ordered the treatment of Phenergan IM to treat the vomiting sign without knowing the actual underlying cause, demonstrating keen quality care to the patient’s health.

The patient was reported to have poor bowel control, and the medical personnel just bathed Ms Jones and placed her back on the bed. Dr Allen assumed she had a gastrointestinal problem due to poor documentation in the healthcare institution. Ms. Jones, on the other hand, would have most likely been diagnosed with the disease preventing enough oxygen from entering her brain if the correct paperwork had been produced (Muinga ae al., 2021). For example, it is claimed that the patient had varying eye pupil sizes before being transferred to another hospital. It is an emergency indicator of a significant stroke condition. However, the medical personnel only checked her vital signs and determined that she was all right. Ms Jones, possibly suffering from a stroke, died due to the healthcare provider’s negligence. She was nauseous and lethargic, had uncontrollable bowel movements, and had unequal pupil size. Those are atypical stroke symptoms that healthcare providers would have noticed sooner to provide the most suitable medical measures.

Similar Post: National Organization of Nurse Practitioner Faculties (NONPF) Competencies

References

Julio, A. G. (2009). Communicating Patient Data and Clinical Assessments Issues in Nursing Documentation, Patient Medical Record (Chapter 3). Nursing Pathways For Patient Safety. p50

Muinga, N., Abejirinde, I. O. O., Paton, C., English, M., & Zweekhorst, M. (2021). We are designing paper‐based records to improve the quality of nursing documentation in hospitals: A scoping review. Journal of Clinical Nursing, 30(1-2), 56-71.

Tajabadi, A., Ahmadi, F., Sadooghi Asl, A., & Vaismoradi, M. (2020). Unsafe nursing documentation: A qualitative content analysis. Nursing ethics, 27(5), 1213-1224.

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Case Study: Late and Later Documentation

According to what you learned from Chapter 3, critique the documentation presented by the healthcare provider and provide examples of whether the nurse followed or did not follow documentation requisites.
Write a paper between the 300-word minimum and 500-word maximum.

Documentation Critique

Use APA format

Three references. Each reference must have been published within the last three years. The textbook can be one of your references.