POOR DOCUMENTATION

Poor Documentation in Patients

Poor Documentation in Patients

Introduction

The main purpose of this paper is to identify the problem of poor documentation on patients. In order to assure the proper records of patients, it is necessary that their documents should be properly developed. Poor documentation means that the records of patients have not been analysed and recorded in a proper way. There can be a number of documentation problems in terms of patients (Allender, 2005, p. 78). The documentation of patients may be time consuming, and expensive. The paper has its emphasis on the poor documentation in the nursing files. Nursing documentation or nursing care files are of utmost importance. These documents are of high priority in all the health institutions. Therefore, it is very necessary for the nurses to keep in mind the importance of their notes and care files. The documentation can cause errors because of the improper records, multiple charts and repetitive recordings. This can cause a legal and practical problem. The paper makes discussion on the documentation problems, and the ways that can be used to solve these problems, and the nurse's role in order to solve problems related to the poor documentation.

Discussion

Nursing errors in documenting the notes file and care files is of great importance. It has been a serious concern for all the health institutions. The number of complains are continuously increasing from the clinical incidents and it becomes difficult for the administration to defend these complaints.

Problem

Documentation is an issue of importance to nursing for many reasons. Quality patient care depends upon complete and accurate information among care givers. Documentation is also an essential component of the accreditation standards and legal requirements imposed on health care organizations. In addition, future costing of nursing care will be dependent upon correct documentation and the ability to link clinical information with financial and administrative data (Allender, 2005, p. 78). Charting procedures must comply with standards of professional and accrediting bodies for the continued accreditation of nursing services. Charting errors can lead to liability, and possible lawsuits for individual nurses are well as for the hospital. In the U.S., hospital payment based on patients' medical diagnoses has made documentation for supporting primary/secondary Diagnostic Related Group (DRG) categories a critical issue for all healthcare providers. In Canada, Management Information Systems (MIS) Guidelines require nursing services to cost out nursing care through documentation and workload measurement systems. Improper documentation of care files and notes files are common in intensive care units, and nurses are often involved in improper documentation of care files and notes file (i.e., identifying, interrupting, and correcting medication administration errors) and preventing adverse outcomes. Although nurses have been recognized for their role in reducing the number of medication administration errors, only recently have nursing strategies for error recovery been described in the literature (Allender, 2005, p. 78).

Why this is a Problem?

The role of nursing documentation is very important in the health record keeping. It is the nurse's responsibility that they should pay proper attention while proper ...