Nurse Requirements And Documentation Medical Essay

Nursing specifications are targets that contribute to public safeguard. They inform nurses with their accountabilities and the general public of what things to expect of nurses. Specifications apply to all nurses irrespective of their tasks, job description or regions of practice. (College or university of Nurses Ontario, 2008, para. 1).

Documentation is one of the vital components of moral, safe and effective nursing practices that provide comprehensible image of your client health status and their effects. (Practice Benchmarks, 2008, para. 2). If the documentation is digital or written format, hence documents communicates the nurse observations, decisions, and outcomes for your client. Based on the Aga Khan School policy of Documents of Nursing Care and attention (2008), "documentation is a primary nursing activity that ensures the evidence for provision of medical attention and continuity of good care. " (p. 1. 1). The quotation signifies that for every occurrences and record it is very important to do documentation as evidence so that the staff would legally be safe. In addition nursing health care provides good and healthy communication between the staff and the individual and further this provides the nice continuity of care and attention to the individual. According to Kimberly (2003), "if it wasn't recorded, it wasn't done. " (para. 1). This disclosed that in the clinical environment, if the paperwork is not complete, then the work will be count number incomplete.

During my mature electives in my own practice arranging in Private Wing II (medicine unit) I encountered many problems with respect to paperwork on bedside files. I observed most of the nursing staff not following a documentation policy. For instance, absence of occurrences related to irregular vital signals, patient response during invasive and non invasive methods, abdominal pain complaint and its own monitoring scale, problems in 24 hours computations of intake result flow sheet that can impact on patient negative and positive balance. Additionally, issues related Nasogastric feeding and patient's tolerance capability, absence of initials and dates on weekends and incorrect addressograph of patient on intake result flow bed sheets, non useable abbreviations, illegible writing and inaccuracy of nursing notes, all these issues recognized during rounds and in morning over. So, I designed and made a decision to bring these paperwork issues in front of my preceptor and supervisor not only to approve my job, but want staff to focus on it so that they would legitimately be safe and performance of the organization should be retained. My preceptor and supervisor treasured me and approved my project which is how my project journey begins. We all nurses understood that documentation is an honest and legal issue and making an individual error in paperwork can put the personnel in lawsuit. Therefore to bring improvement in personnel documentation practices also to observe personnel knowledge I developed a questionnaire tool. At last, I come to summary that personnel really must work on records as there is a gap identified in a few of the staffs knowledge about documentation. Both preceptor and administrator appreciated me and invite me to focus on it as issues of records on clinical setting quite common now a day that does not only place the staff in trouble but this may affect the business. Therefore, I talked about all the related problems with respect to paperwork with preceptor and supervisor and lastly the project approved by them. Medical director and preceptor considered that work on documentation is a good project so that staff should think than it and work on it to be able to bring improvement in their paperwork rather than make further mistakes that can affect the patient quality of care as this is an ethical issue. For assessing the need of the determined subject matter, I developed a pre test questionnaire predicated on staff understanding of nursing documentation and finally I come to conclusion via assessment that staffs really have to work on records as a few of the staff possessed insufficient knowledge regarding nursing documentation. A number of the personnel have knowledge but do not show accountability which can put the machine and other staff in trouble. I also identified other issues for practice structured project. Firstly, non conformity to infection controls policy. The purpose of not selected this issue was that, all the products Mind nurses, Clinical Nurse Trainers (CNI) and Infections Control Workers are working together on it. Furthermore, they do reinforce unit staffs to wait the problem control periods on continuous basis not only to prevent them but also avoid the other participants and patients from infectious diseases. Second of all, bed sore issues are the most frequent problem I determined in unit. The reason behind not selecting this issue was as the truth Manager of the unit already made a job onto it, she performed rounds on daily basis and every month she takes consultations on foundation sores for the personnel. Thirdly, communication difference among the staff and patient. For that, CNI and Mind Nurse (HN) are taking classes of morning hours and evening shift staffs on regular basis.

In order to aid the need of the task, I reviewed the previous quarterly inner audits results of medical documentation, which proved that staff will not following the concepts and the policy of nursing paperwork. The primary observations in these audits were non useable abbreviations in medical records and in flow mattress sheets i. e. @, cc, KCL, etc. Additionally, unauthorized staff records, incorrect addressograph and wrong calculations of a day documented and recognized in intake output circulation sheet in the month of February 2010 - May 2010. The major observations which I found through the rounds were almost same except one which includes not mentioned in audits observation was the happenings of patient complain, abnormal vital signals and invasive and non invasive procedure that I recognized. All these issues have finally become the main concern of a device. Therefore, being truly a responsible staff I made a decision to take this job as an effort and plan to focus on it. As the paperwork is an ethical and legal concern that provides quality good care to the patient. Moreover, records is a basic tool of communication where nurse does assess patient's condition to be able to record patient's details, so that staff would legitimately be safe and patient care and attention not affected.

Based on above observations and from the audits results, I developed a pre test questionnaire matching to staff need that contains 15 questions. For keeping dependability of the questionnaire it was checked out by the preceptor and facilitator. After substantiation of the pre test, I managed to get fill with the Medical Associate (NA's) and Registered Nurses (RN's). I got 20 samples of the staffs that were 40% staffs of the unit. Although pre test require 15 questions but I scrutinize the five major main concern questions of the test. An assessment results reveals that 65% staffs answer effectively about the best explanation of nursing records. Additionally, 50% staffs did correct answer deliberately of 24 hours of intake result balance paperwork. Furthermore, 25% staffs answer appropriately deliberately of intake out put documentation in circulation sheet. Besides this, 50% staffs provided correct answer on liable of documenting IV fluids and intake output calculations of 24 hours.

Analysis of the issue with evidence structured literature:

According to Aga Khan Insurance policy of Documentation in Nursing Good care (2008), "Patient record is a legal doc; therefore must present legible, accurate, well-timed, objective and complete information about patient and intervention. (1. 2). This meaning clearly explains the standard documentation that are essential for many nursing staff in order to be officially safe as records is an ethical and legal concern all around the globe. Relating to Connor, K. et al (2007), "nursing documentation has a higher priority in all trusts because research of records of good care and observations has unveiled that use of multiple charts and repetitive recording causes functional and legalities. "(para. 2). The aforementioned quotation shows that repetitive documents make a difference patient's quality of care. Moreover, this can take the personnel in law suit. Furthermore, organization performances would get affected if it's used the courtroom. Hence, this has been noticed that insufficient thorough documentation and nurse accountability uncovers many grievances and investigations due to clinical incidents that have been leading to indefensible says for the personnel. Corresponding to NMC (2002), "Vigilance must ensure high criteria in record keeping, whether details are in written or electric form. The audit of patient documentation is a element of risk management that can help to market quality of good care. " Hardwood, C. , (2003) assume that any notes or files demand legal paperwork, if any judgment, hazy or unsubstantiated records found, it would be difficult to maintain professional stability in the judge. (para. 2). Hence, good record keeping promotes better communication as well as continuity, steadiness, efficiency that further reinforce professionalism and reliability within medical.

Integration of the Model:

I run this project through PDSA model, visualized by Walter Shewhart in 1930's and further this was followed by W. Edwards Deming in 1950's. This model is known as Shewhart pattern, Deming circuit, Plan-Do-Study-Act cycle, and Plan-Do-Check-Act cycle. Also called Learning and Improvement pattern. In this model, the pattern shows the platform for the improvement of a process or system. (Refer Appendix A). Regarding to Kevin (2008), once target improvement areas identified, the model will provides a framework that can further used to guide the entire task or to develop the precise objects. (para. 2). Furthermore, the PDSA pattern also used whenever starting a new improvement task or when applying any change. Besides this, PDSA circuit also used as a model for continuous improvement in quality health care. Matching to Tague (2004), The PDSA pattern has 4 steps to carry out the change. Just the circle has no end; it ought to be repeated over and over for ongoing improvement (para. 3). Taking this aspect I'd add that in the same manner unless the personnel brings change and improvement in them, ongoing periods for the paperwork, activities of documenting records quizzes and overview of policies should be continue. Here I would incorporate this model with my project. The first step is plan, in this task I identified the area that requires improvement. Furthermore, I collected data and planned strategies appropriately for change. I identified four issues from the unit and analyzed the significance of each concern. I talked about each problem with my preceptor and designed for prioritizing the issues. Moreover, CNI planned a gathering with unit director for selection the goal concern for the job. Finally after the conversations and come to bottom line I selected this issue documentation predicated on staff knowledge, frame of mind and practices during the clinical environment. I gathered data through observations during rounds and knowledge identified via pre test. I designed strategies for implementations, that is program consciousness and develop impressive flyer. Moreover, consult with CNI that PowerPoint presentation should be done via multimedia and then for the nursing records activity White Mother board with markers should be needed. The next step is do, in this implementation of the job done. I conducted three trainings on different days and nights for all the staffs. I carried out the procedure in the evenings switch staffs. Moreover, for every time I developed an progressive flyer, and pasted on found plank for the announcement of the treatment. (Refer Desk 1. Action Plan). Furthermore, I trained and prompted the staff how to get the policy on the computer.

For sustainability of the task, I discussed with all associates about the results of the job. Moreover, I explained them that for performance of the project's results they have to initiate the staff and take the duty to see the staff's documents techniques in their shifts. In addition, I arranged a meeting with the medical documents monitors of the machine and present them the duty conduct operating sessions in every fifteen to twenty days. The third step of the model is research, for this I searched many relevant literature that supports my nursing paperwork project. And If I take the aspect 'check' of PDCA model I examined the personnel by post test; Moreover, I present different scenarios for the personnel, based on documentation practices where staffs have to demonstrate documentation according to its concept. Furthermore, I took the redemonstration of the procedure of retrieving paperwork policies and observations to judge the staffs on their nursing documentation practices. The fourth and previous step of the model is work. In the act stage, first I used power point display lecture with two way communication, and proved pamphlets and cards which I designed for them for my sustainability. It is determined that the improvement has come in them or not, whether their practices transformed or not. Improvement practices bring evolved in them or not. Because of this project the time was short, therefore i could not in a position to perform this step completely but I handed all my what to CNI and the volunteers for even more proceed the procedure.


Implementation is the main element of the job. I applied multiple strategies in order to put into practice the project effectively. My first strategy was to provide knowledge to personnel about the documents and its practices. I searched many literatures on the determined issue and review and retrieved nursing documentation policies and further consult with my preceptor and facilitator. Also developed PowerPoint presentation slides on the specific project. According to Green, Palfery, Clark & Anastasi 2002, " The slides act like lecture and work very well for initial explanation and clarifying the principles of the learners. " (p. 2). To see the enhancement knowledge of the personnel, I showed electricity point display slides to the personnel, before conducting the program I also showed the slides to my preceptor and facilitator. After justification of the demonstration, I conducted three classes on different times. The reason for three trainings was to broaden information to different sets of staff. I perform all my sessions in overlapping timings and the majority of the time night time staff go to my session rather than morning. I considered, this strategy was appropriate and relevant to the practice because mosts of the nighttime staff does sign up for the classes on different topic so they don't have to tense they are supplying extra timings to the task or applying any initiatives. Green, Palfrey, Clark & Anastasi 2002, "The slides act like lecture and work very well for initial justification and clarifying the concepts of the learners". (p. 2). In addition, I urged the personnel to participate actively because this can help the staffs expressing out their views and carried out their personal activities and find out different concepts via teams. "Group discussions are best for problem resolving, critical thinking and demonstrating different items of views among learners. "(p. 1). My second strategy was to teach the procedure of retrieving the records coverage for the personnel and encouraged the personnel to re show it. Also redemonstrate the nursing notes to be able to see the procedures of the personnel following A-G diagnosis. The strategy was very effective because here I come to know the staff methods and their knowledge. According to Rodrigo, Meredith& Moore 2003, "Kinetics learners learn by doing and favor learning which involves movement, active participation, and concrete things. (p. 1). My third strategy was to develop an ground breaking flyers which i pasted on the unit notice table for the reinforcement and remembrance of the staff.


In analysis, for RNs I distributed nursing notes paper to see their documentation

practices Furthermore, I asked staffs about the Aga Khan College or university documentation insurance policy. For

nursing assistant (NA) I sent out intake output move sheet where I asked those to document

routine amount of substance intake measurement. Furthermore, I asked the staffs about the

documentation error coverage. It is expressing that no project will be successful without knowing its

outcomes. Following the execution I performed an evaluation of my display. After

providing them the time on documentation, I came across t medical staffs could actually clarify their

concepts about the documentation and its mistake policy. To see the base collection knowledge

among staff regarding nursing paperwork. For that purpose, I have applied evaluation tool

on nursing records developed by me, after preceptor's information and approval. (See

results of analysis (Refer Appendix B). The implementation analysis reveals that 85% of my

project went efficiently (Refer Appendix C). Furthermore, staff participated well; show the

realistic samples related clinical. In addition, suggested to possess these sorts of sessions on

quarterly basis so that to enhance the knowledge. Furthermore, also recommended to have an activity

on nursing records in order to bring change in records practices.


Time period for project was short that's the reason unable to entail all staff in

implementation of the job. Another reason for not going to the program by staff was, most of

the staffs were busy in providing care to the patient. Additionally, for the analysis of task I

have fourteen days in discovering needs, selecting concern issue, observations, evaluation and

evaluation of the project which was a great obstacle for me personally. Furthermore, lack of resources was

a big issue as Learning Learning resource Middle was full the majority of the time and lots of budgeting issues

for assessment, analysis and on articles but with the great support of preceptor and ongoing

facilitation by my facilitator made my entire life easy in the completion of running the project

successfully, easily and timely.


There are certain tips with regard of nursing documents. Policy of

Documentation should be evaluated on daily basis in device for the data and bring

improvement in medical documentation. Secondly, lessons, quizzes on the nursing

documentation should be conducted every month by assigned medical staffs or Clinical

Nurse Instructor (CNI) in order to observe staff knowledge. Furthermore, 8 steps of

audit checklist have to be followed and referenced. Moreover, nursing documentation should be

done by utilizing audit tool every quarterly, for the improvement of practices

and monitoring of conformity to documentation insurance plan.


To conclude, I am going to say that records plays a essential role in medical practice because

this communicates health care providers about patient analysis, planning, interventions

and analysis of the patient condition. Furthermore, it an ethical issue that is clearly a legal

documentation and eventually this safe staff for any legal actions. Paperwork shows

honesty and care for the patient which should be done promptly. If health care is not recorded, it

means it's not done.

In the previous, I'd say that this project increased my learning. It provided me an

opportunity to are a team member with personnel, Head Nurse (HN) and Clinical Nurse

Instructor (CNI). This task also enhanced my control style what I discovered the concept in

class. Despite of all this, the project helped me to work individually and to research about

nursing documentation comprehensive. Moreover I discovered to combine new principles and model that

would further help me in my own profession profession.

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