Documentation is any communicable material, which is used to explain some attributes of an object, system or process. Many a times, technical or medical writing skills are taught to the person who seeks to take responsibility of writing documents and it will be discussed in this paper…
This essay approves that despite so many potential beneficial aspects covered in the nursing care plan, it continues to be regarded as a mere additional burden to work or just a waste of time. It is a sorrow to see this reflection of some experts in the healthcare system. A document as an additional attempt to make more scientific and applicable the care system is the nursing care document. Its preparation, maintenance, usage, application, and respect can certainly add to the good documentation practice. And good documentation practice has always been a preferable and better means of good communication.
In an attempt to explain the crucial points for patient’s care, a nurse may be required to depart from much of her on-duty time. This loss of time can also become a cause of less potential care imparted to the patient in the span of specific time. A plan, its document can ease the need of explanation and ensure more specificity and knowledge to the learner.
This report makes a conclusion that it is thus essential to maintain twenty-four hour outcome summaries in documented form. The document should be updated daily in the progress notes by the responsible registered nurse. This nursing care plan document should include any difficulties observed during the process of achieving the set goal. It should also include any changes and or/ deviations that were made in the care plan and family’s contribution in an attempt to achieve the document specified goal. The plans that are required to address an incurable but manageable ailment or symptom should be addressed. ...
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According to the report nurses are crucial members of the health care fraternity. They serve in various settings such hospitals, nursing homes and doctors’ offices. In addition to the education and training requirements, it is imperative for them to be well-rounded individuals who possess many other skills and are able to improve their effectiveness in the job.
The mind and body greatly interconnected for the mind controls the body. A relaxed mind equates to sound decision-making and function of an individual. A stressed mind is an unhealthy mind. The American Psychological Association (APA) reported in 20102 that “less than half of all Americans (40 percent) perceive themselves to be in excellent or very good health” with a similar number saying their “stress levels have increased over the past five years”.
A Formal Academic Research-Supported Essay Introduction Communication can be referred as the foundation stone in the development of children. Communication should not be considered as the oratory skills in the symbolic languages. Communication is an important process that begins right from the birth of a baby (Klein, Cook & Richardson-Gibbs, 2001).
Nurses are supposed to keep record in a correct manner in order to report certain observations and conclusion on drawn from those observations. These documents usually accompany nurses’ practice and used in his conjunction with nurses’ support and publication.
A good professional will always make clear written evidence of his/her work in order to provide patients with continued care and maintain one's own professional knowledge and competence. Furthermore good record keeping shows the respect to a patient and the patient's needs.
However, in the present scenario documentation has become an essential need of people of all professions and from every sphere of life. A well-documented form of communication adds benefit to the confidence of the action and improves ability. The importance of the old saying "if it's not documented in the medical record it was not done" has been visually and intellectually expressive in the present time of increased law and order in every section aiming for survival.
The relevance of the work is in the fact, that there still exists a serious gap in describing the problem and offering possible solutions.
The literary sources, related to the problem of documentation in nursing, is full of examples and descriptions of the cases, when the inaccuracies in the nursing documentation caused serious misunderstandings, failures in medication and care for patients, and could possibly become a subject of litigation.
Records entails the information created or received for action, people-entails the records contacts, records staff and the Records Liaison Officers in charge with over seeing the records management program. Processes involve the procedures
The mind and body greatly interconnected for the mind controls the body. A relaxed mind equates to sound decision-making and function of an individual. A stressed mind is an unhealthy mind. The American Psychological Association (APA)
These plans should be developed in collaboration with the service user. Care plans should also contain details of intervention that are to be provided to help the individual service user during their recovery from their mental health issues (Tunmore et al., 2000;
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