Essay Nursing Process
Conclusion Documentation is an important process in nursing that should be taken in consideration. Moody, Ph D, MPH, FAAN, Elaine Slocumb, Ph D, RN, Bruce Berg, MD, Donna Jackson, MSN, RN, BC. Electronic Health Records Documentation in Nursing: Nurse’s Perception, Attitudes, and Preferences.
It is important to study any implementation in nursing documentation and the effect of this implementation on the nursing documentation process which is used for patient’s safety.
The first stage of the APIE is ‘assessing’, which entails a thorough analysis of the presenting complaint and the overall account of the individual patient (Hill, 2015).
The assessing process is not a list of presenting problems, but a more systematic integration of quantitative and qualitative data.
It is needed to meet legal and professional standards.
By documentation the nurse can communicate with other health professionals.
If this system will not provide any improve in care, why we have to use this technology. Agency for Healthcare Research and Quality Guide to Health Care Quality How to know it when you see it.
In my opinion I think EHR might improve the client’s quality of care because it will take less time in documentation, it is available at any time, and there will be less chances to lose any patient information.
I have to take in consideration that most of the 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.
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.
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.