There are more things we have to provide for the patient to improve the best quality of care, the most important things that we should practice the updated evidence-based practices on our documentation.
Can written nursing practice standards improve documentation of initial assessment of ED patients?. I have to take in consideration that most of Collection and documentation of health history essay staff is not having any idea about computer system, so to study this topic we have to educate the stuff about the computer and how to deal with it.
Method Inform Med; Electronic nursing documentation in primary health care. The topic that I choose is the effect of computerized documentation on the patient quality of care and compares it with effect of the written documentation.
Electronic Health Records Overview. It is a technology that keeps the information secured and private, at the same time it is available 24 hours 7 days a week for the health care professionals in the hospital itself or in the all community.
To improve the patient quality of care we need to reduce the errors in documentation, by providing safer care to the patient, dealing with the patient for longer time to provide more care, and keep the patient health records safe and secure.
Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunization, laboratory data, and radiology reports. I derived this topic from the articles that I have read and from the community that I have experience on Abu Dhabi, Mafraq Hospital.
The quality of care has many concepts, to decide the concepts of the care quality I have to review the literature to know what are the quality concepts to study on and suitable the community that I want to make my study on.
It supports the vision guiding the plan: If this system will not provide any improve in care, why we have to use this technology. Electronic Health Records Documentation in Nursing: Implementing computerized documentation and its effect on the quality of care that is provided for the clients will need to be studied.
Conclusion Documentation is an important process in nursing that should be taken in consideration. Research Question To study if the electronic documentation provide enhanced quality of care more than the written nursing documentation.
Then we have to compare these two and see if the EHR can improve the patient quality of care or not. I choose this topic to study the implementation of the electronic health records and how it improves the patient quality of care.
Australian Emergency Nursing Journal. I know there will be some good things from using computerized systems for example it is not coasting a lot there will be no papers to be used, no manual files which will need a big space in the hospital to keep it in, and it is more secured and safe than the written documentation, but we should be sure that there will be an improve in the quality of care or at least the quality of care will remain same to the one with the written documentation.
Five Articles chosen for the topic: In my community most of the nursing staff has no idea about the basics of the computer so they might face problems while dealing with the computer systems which this might affect the documentation process which is used for the patient safety, but before telling these things we have to do so many studies before implementing the EHR system and after implementing it.
It has the ability to generate a complete record of clinical patient encounter, as well as supporting other care-related activities directly or indirectly via interface-including evidence-based decision support quality management, and outcomes reporting.Documentation of Medical Records - Overview What is documentation and why is it important?
• Medical record documentation is required to record pertinent facts, findings, and observations about a veteran’s health history including past and present illnesses, examinations, tests, treatments, and outcomes.
Nursing Health History Nursing health history is the first part and one of the mostsignificant aspects in case studies. It is a systematic collection ofsubjective and objective data, ordering and a step-by-step processinculcating detailed information in determining client’s.
Health history is the first and foremost part of any medical examination.
This data helps the physician to understand the physiological, psychological and sociological problems of the patient and gives a clue to the physicians for their treatment (Desmond & Copeland, ).
Collection and Documentation of Health History Purpose of Health record Health history or health record is a systematically created document which stores the complete history of the diseases and physical conditions of the patient. Obtaining a valid nursing health history requires profes-sional, interpersonal, and interviewing skills.
rushing someone through the interview process undoubtedly causes important information to be. NURSING DATA COLLECTION, DOCUMENTATION, AND ANALYSIS. COLLECTING SUBJECTIVE DATA is an. NURSING DATA COLLECTION, DOCUMENTATION. Example of a Complete History and Physical Write-up Patient Name: Unit No: Location: Informant: patient, who is reliable, and old CPMC chart.
Chief Complaint: This is the 3rd CPMC admission for this 83 year old woman with a long history of hypertension who presented with the chief complaint of substernal “toothache like” chest pain of 12 hours.Download