Nursing Bedside Report

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.

Communication in the operating room is very important. If surgeons and nurses are not communicating effectively it can directly affect the quality of patient care and safety. In 1999, the Institute of Medicine (IOM) issued a report, To Err is Human: Building a Safer Health System, which estimated the fifth leading cause of death in hospitals in the United States was due to health care errors (Mason, Gardner, Outlaw, Freida, 2016). To help reduce these errors, effective communication needs to be exercised throughout health care.

Objective One During my clinical day three, I demonstrated entry-level competence in professional nursing practice in caring for patients with multiple and/or complex unmet human needs. I addressed safety needs, safety in medication administration, effective communication, and surveillance for my patients. First, I addressed safety needs my ensuring the appropriate safety measures were implemented for the patients. Some of the safety measures included, wearing non-skid socks, wearing a yellow armband which indicated fall risk, keeping the bed in lowest position, two side rails up, bed locked, and the call light within reach.

The projected goals and outcomes of this project are to increase quality of report, increase patient safety and increase patient satisfaction. Introduction This paper proposes to outline the impact of a standardized bedside reporting system that involves the patient as opposed to the age-old report method conducted at the nurse’s station between only nurses. Evaluation of this impact includes quality

Evidence and Evaluation in Bedside Reporting Bedside reporting assist nurses with a chance to improve patient safety and increase patient collaboration in the arrangement of care. There is also less care correlated to inaccurate or deficiency of information because the report process includes actual patient apparition. Increased staff approval with bedside reporting supports teamwork and supports accountability. By associating bedside reporting there is an optimistic impact on the patient and their relatives.

Communication in nursing is known for its life saving success as well as its greatest flaw in poor patient outcomes. There is always room for improvement and when communication is carried out efficiently, healthcare professionals have reaped the benefits. However, there have been many instances in which nurses have had to learn the hard way of how detrimental communication can be to patient safety. Through research and reviews of literature, the topic of patient safety related to handoff communication among units is analyzed.

Patient safety experts have demonstrated that “patient safety increases when teamwork and collaboration skills are taught and empowered; when teamwork and collaboration are not present, medical errors will result” (Creasia & Friberg, 201, p. 348). As a nurse, it is imperative to collaborate with other interdisciplinary members in health care and also strive to research and implement evidence-based practices. Evidence-based practice is necessary to “ensure the highest quality of cost-effective care and the best patient outcomes” (Fineout-Overholt, 2011, para. 16). With a collaborative and innovative attitude on safe health care practices, an increase in patient safety and effectiveness of care will

Proper communication and interaction are some of the most fundamental elements of successful nursing. It is very easy to occur a miscommunication when not all the healthcare providers are in same pace. Miscommunication can occur during end off shift report among the nurses. Some of the factors of miscommunication includes; it is a busy time when nurses are giving report, they are tired, wants to make shortcut, and language barrier. Furthermore, nurses that are trained in foreign country have difference in nursing practice.

As a bedside nurse, I believe that it was significant that Lewis’s crisis developed over the weekend. Typically staffing levels are lower on the weekends and staffed with less experienced staff. I currently work at a teaching hospital and this is true to some extent at my hospital. However, we have a rapid response team that operates inpatient 24/7. The team consists of a registered nurse and a respiratory therapist.

The information is automatically gathered by the ICU information system; nurses have the option of either accepting or modifying the data. In typical clinical settings, nurses perform the selection and transfer of bedside monitoring data from the ICU information system to the EHR about once an hour. These ICU information systems typically retain the high frequency bedside monitoring data and can achieve near-real-time computerized decision support. In many cases, the nurse’s notes are also entered into the ICU information system-generally once per shift-and some summary vital sign information may find its way into those notes. Physician progress notes are also entered into ICU information systems in a similar fashion.

Nursing handover also known as end-of-shift report is a complex and patient specific process that involves transferring patients’ information and plan of care to ensure safety and continuation of optimal care. As noted by Caruso (2007), change of shift report signifies a time of careful communication in order to promote patient safety and best practice. There are many different ways nurses can give a shift report. Written report, phone recording, or verbal reports in a designated room, nurses’ station, or at the patient’s bedside are all possible ways to give shift report (Caruso, 2007). “Potential adverse events associated with inaccurate or untimely clinical handover has been established...

In the leadership in care delivery course, we were assigned to a hospital to perform clinical hours and provide care to four patients. Additionally, the purpose of this paper is to explain and provide examples on how our patient care included the concepts of Quality and Safety Education for Nursing (QSEN) competencies, delegation, handoff reporting, and a reflection of the clinical experience. Quality and Safety Education for Nursing (QSEN) Competencies QSEN consists of six competencies: patient centered care, quality improvement, teamwork and collaboration, safety, informatics, and evidence based practice. To provide patient-centered care, I had to educate the patient when administering medications on why the patient was taking the medication and side effects. Care had to be individualized with each patient and it included providing respect with his or her decisions in their care.

Contributing factors to their conditions may be forgotten or unknown to one physician and therefore accurate diagnosis and treatment can be made much more difficult. Aspects of health can be easily overlooked however when interprofessional practice is undertaken, the risk of adverse events occurring diminishes. This essay shall highlight the role of nurses and paramedics; touching on how change-over nurses communicate information regarding patients’ health and behaviours over the duration of the time spent in one nurse’s care to the next at the end of one’s shift. Paramedics on the other hand, do not have all the time and resources that nurses do and so must carry out their communication with more precision. Preventing excessive costs and repetitive medical tests interprofessional clinical practice fast tracks patient care to keep patient turnover in hospitals and clinics at a steady rate.

Nurses fatigue is growing problem nurse face each day in the healthcare environment, and he can be caused by long hours, sleep deprivation, and possibly by accepting extra assignments can be dangerous for both nurses and patient. These inadequacies can result in major implications for the health and safety of registered nurses and can compromise patient care which can lead to fatalities. (American Nurses Association, 2014). In my experience, being fatigued from working much 12-hour shifts consecutively was very difficult as I felt extremely tired, resulting in lack of focus, missing important details during the handing over the process with impaired cognitive functioning. This I found was detrimental to the patients and myself as it impedes quality and has a deleterious effect on patient safety.

The communication between nurse and patient is one of the basic principles in nursing care and is of the important strategies for improving the quality of care(1).communication level between nurses and patient is one of main patient experience(2). Several studies have identified communication as a pre-requisite for revealing patient symptoms, concerns, and issues, and thereby an important skill to obey of the treatment, diagnostic, health promotion, and rehabilitation programs(3-5). Considering the importance of good communication in care, significant issues such as lack of information, inappropriate information and lack of accountability are still reported in patient satisfaction surveys.(6)One of the most important issues in improving the