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High education and motivation are needed to achieve good nursing documentation. Documentation, it is important in nursing. This is evident from Dion(2001)as cited in Owen (2005), where she states that accurate records not only ensures quality of practice but also safeguards the nurse by providing evidence of his or her professional ability. Thorough documentation in the medical record may be the best evidence that appropriate care has been provided. And according to Iyer and Camp in Nursing Documentation: A Nursing Process Approach, "Timely, accurate, and complete charting helps the patient secure better care and protects the nurse, physicians, and hospital from litigation."1 nursing documentation that is used throughout an organization. ANA’s Principles for Nursing Documentationidentifies six essential principles to guide nurses in this necessary and integral aspect of the work of registered nurses in all roles and settings. American Nurses Association Quality improvement in clinical documentation: does clinical governance work?

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Nursing Standard. 29, 14, 44-51. Proper nursing documentation prevents errors and facilitates continuity of care. Charting should include not only changes in status, but what was done about the changes. For instance, consider a patient whose condition is deteriorating and the nurse charts her observations and discussion with the … 2005-04-19 Journals Articles. Search by keywords: In the field: Search. Close.

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American Nurses Association Quality improvement in clinical documentation: does clinical governance work? Mahlegha Dehghan,1 Dorsa Dehghan,2 Akbar Sheikhrabori,3 Masoume Sadeghi,4 Mehrdad Jalalian5 1Department of Medical Surgical Nursing, School of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, 2Department of Pediatric Nursing, School of Nursing and Midwifery, Islamic Azad University Kerman … Journal of Advanced Nursing 53(2): 151–9 Crossref, Medline, Google Scholar; Jefferies D, Johnson M, Griffiths R (2010) A meta-study of the essentials of quality nursing documentation. Int J Nurs Pract 16(2): 112–24 Crossref, Medline, Google Scholar This is because documentation is evidence that the patient received proper care.

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Nursing. Fulltext and references.

ANA’s Principles for Nursing Documentationidentifies six essential principles to guide nurses in this necessary and integral aspect of the work of registered nurses in all roles and settings.
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Provides authoritative medical information on medicine, nursing, dentistry, veterinary Rich with full-text documents, this database includes medical and consumer  European Scientific Journal January 2016 edition vol.12, No.3 ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431 102 According to Irving et al (2006), nursing documentation can be The nurse's documentation is read by lawyers and experts when a lawsuit ensues. Every microscopic detail of the medical record is examined by the lawyers and the expert nurses that they employ to make a case for their side. They're looking to see what went wrong and what could have been done better. The quality of nursing documentation has consistently been found to be failing to meet recommended standards. This article will provide an overview of the literature on record-keeping practice and examine what makes good quality record keeping and the factors that prevent nurses from achieving good documentation standards.

The current practice of implementing falls prevention strategies for Se hela listan på nursingcenter.com The American Journal of Nursing, the profession's premier journal, promotes excellence in the nursing and healthcare profession.
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Affiliations · Melissa Yates, BSN RN. Melissa Yates.