Bedside Report Evaluation

They should be hold accountable for any breach in protocols. • Present format for electronic documentation does not allow for comprehensive clinical documentation during follow-up visit. Efforts should be made to upgrade the electronic medical record system to the standard of that expected for a medical center and research institute. This is to allow for proper documentation according to the industrial standard, and easy retrieval of patient’s information for clinical research. There is a need to employ a clinical documentation improvement specialist (CDIS) in this

Overall, incomplete documentation and delinquent medical records cause inaccurate reimbursement and results in inaccurate gross revenue to the hospital. It can have a negative impact on the hospital budgeting and financial planning process for the hospital. It is for this purpose that every healthcare institution should be purposeful on reviewing the accuracy and completeness in clinical documentation, no matter the cost. Even though, for most physicians, most of their time is focused on the actual care of the patient and there is little to no time to devote to extensive documentation, it is imperative to understand patient care includes both the one-to-one attention and the documentation of said treatment.

(2010). Johnson (2015) and Evans et al. (2012) discuss the overall process of implementation of a bedside report along with outcomes. Johnson (2015) however, additionally highlights Lewin’s change model in the study. Friesen, White, and Byers (2008) reveal issues with different methods of report and their implications and Racco (2014) discusses the bedside safety check process.

As a nursing student I am taught how to document using special medical terminology, and the importance of documenting, however the article “Stay Out of Court with Proper Documentation” by Sally Austin confirms just how critical it is to be accurate, timely, and unbiased with patient documentation. Proper documentation not only helps keep the patient safe, but just as importantly protects the nurse should a lawsuit occur. Austin’s article defines the legal terms used in the more common lawsuit, negligence, involving nurses and how to avoid them. First, the patient must prove four things in order for a lawsuit to be deemed in their favor: A duty to the patient existed, a breach of duty occurred, the patient was injured, and lastly the injury

The idea of shift work is a common one, but for nurses this is not a simple changing of staff during a certain time, change of shift signifies a time of purposeful communication between nurses and patients, in order to promote patient safety and best practices (Caruso, 2007). During this time, there is the possibility for this critical opportunity to relay important information to become disorganized by extraneous information, rather than concentrating on the needs of the patient (Sullivan, 2010). Often the patient is left out of the conversation, and is not a part of the process. Patients and families can play an important role in making sure these transitions in care are safe and effective (AHRQ, 2013).

With the use of consistent handoff tools, there is likely not a missing piece of information that leaves the receiving nurse with gaps in any information. The inconsistency of use of different tools such as SBAR (Situation-Background-Assessment-Recommendation) or electronic handoff methods is where information gets lost. The use of SBAR is commonly used to maintain uniform communication. In example of the use of SBAR against the situation mention earlier, the known history of imprisonment with bloody sputum were not mentioned in the background or assessment piece of handoff. Not only did this impact patient safety but also the safety of nursing staff.

What particular value will the nurse representative bring to the board unique and different from that already presented? Nursing provides the highest amount of patient contact care, providing care at the bedside throughout out the patient’s entire stay in the hospital. Fran Roberts, Ph.D., RN, FAAN, makes an excellent point when she describes a nurses perspective of a hospital from the inside out, offering a view that no other healthcare provider can (Roberts, 2014). Dr. Roberts goes on to explain that this unique perspective provides insight that no other board members can bring to the table, such as what it 's like to work short staffed, at what point patient safety becomes compromised, and experiences that no one can offer other than another nurse (Roberts, 2014).

Points of care solutions are medical diagnostic testing or documentation done at the patient 's bedside. At my work we us point of care documentation, meaning that the nurses do their documentation in the patient 's room. Research shows that point of care solutions “reduces inefficiencies, decreases the probability of errors, promotes information transfer, and encourages the nurse to be at the bedside” (Duffy&Kharasch, 2010). However, point of care services has been reported by patients to make them feel alienated for their care providers because the nurse 's attention is on their charting and not the patient (Duffy&Kharasch, 2010). This has the potential to “compromise the nurse-patient interaction” (Duffy&Kharasch, 2010).

A total of fifteen staff members along with five patients participated in the meetings. Members in attendance varied between a low of five to a max of ten, for the two meetings. At the first meeting, an overview of the hand-off report was presented. The problem of hand-off report was addressed and discussions of ways to improve the reports were debated. A survey was then given to the participants to evaluate the concerns and potential ways that may help improve the current problem with end-of-shift report.

Paper 2 – Rough Draft Over the intercom you hear “Code Blue, 2nd floor, room 117.” You hear doctors’ pagers ringing and see a herd of staff rushing into a patient’s room. The hospital is a hectic place with many on-edge people. In medical facilities, it is common to use codes as a means to announce a situation to the medical staff without alarming the patients or visitors.

A.During the early 20th century, standardized terminology was adopted, which described patient mortality and morbidity. The International Classification of Disease (ICD) formalized the terms, which has increased in recent years to etiology and diseases. We see them today in the hospitals such as the Glagow Coma scale and APGAR; however, they are limited to a small region of patient care. The American Nurses Association (ANA) and saw that value in documentation, which needed to be standardized in order for everyone else to see its value. The transition required a change in thinking and change in how nurse document.

Poor communication is so important that the Institute of Medicine identified it as the cause of many medical errors (Institute of Medicine, 1999). The Center for American Nurses (2008) defines disruptive behavior as “behavior that interferes with healthy communication among providers and adversely influences performance and outcomes. For instance, at the beginning of the placement, I found a reason behind the occurrence of client errors and missing nursing interventions that is insufficient communication among my teammates. Meanwhile, I have learnt a more systematic presentation to turn over cases and apply. Standard protocols, such as SBAR (situation-background- assessment-recommendations) are now commonplace as a way to improve communication (Beckett & Kipnis, 2009).

Quality Nursing Care - Summative Essay Abby Smith A8a Introduction I will be using Driscolls model of reflection (2007) to look back and reflect on how my concept of Quality Nursing Care (QNC) has advanced and also how that has adapted me for practice. Reflection is a crucial tool to help achieve continuous lifelong learning in the nursing profession because by using this tool Nurses can collate both their academic understanding and nursing practice. (Fawcett, 2006). Reflection can be used to educate ourselves by looking back on previous care given and seeing how it can be improved.

When I picture myself with patients, I see the fear, uncertainty, confusion in their face as I carry on their cares. Stepping in to help patients reach their health goal is very important as far as health care is concern. Zomorodi and Foley (2009) define “the role of the advocating nurse as informing and

Therefore, with handovers, the nurses will be able to assess, plan and delegate tasks allocated effectively (Johnson et al, 2012) and thus, task can be completed within the shifts. Nevertheless, the handovers in the current practice has not been improved, according to the research done by Poot et al (2014), usually interrupted by phone calls and lack of active inquiries and confirmation regarding patients’ conditions by the oncoming shift nurses, which might impair the health outcomes of the patients if the message delivered is inappropriate. Therefore, it is the duty of the healthcare managers to audit the handover so that delivery of care is of standards and any changes to the practice can be issued out (Mayor et al, 2012). Besides, the managers should participate in patients’ care and be part of the team to supervise the overall teamwork and become a role model to the nurses (Tschannen et al, 2013). Only that nurses at