Chapter 49. Documentation and the Nurse Care Planning Process
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Assignment Is a Complementary Relationship Between Nurse and Bhts and Bhas That Results in Safe and Efficient Patient Care If It Is Used Appropriately
Unity Center for Behavioral Health Assignment is a complementary relationship between nurse and BHTs and BHAs that results in safe and efficient patient care if it is used appropriately. It is a critical step in the delivery of nursing care. This Photo by Unknown Author is licensed under CC BY-SA-NC 1) Define assignment and how it relates to nursing practice. 2) Explain the difference between assignment and delegation. 3) Define the roles and responsibilities within assignments of BHTs and BHAs. 4) Review the the correct steps when assigning tasks to BHTs and BHAs. 5) Review assignments, ethics and standards specific to the psychiatric mental health nurse. Assignment has a specific meaning in the Nurse Practice Act. OAR 851-06 defines the term assign as “...directing and distributing, within a given work period, the work that each staff member is already authorized by license or certification and organizational position description to perform.” Unlicensed assistive personnel (UAP) are unlicensed health care providers trained to function in a supportive role by providing patient/client care activities. When the activity to be performed is within the UAP’s position description, and there is documented education and current competency validation of the UAP having been done by the organization employing both the RN and the UAP staff member. The UAP is held accountable for the performance of their role. KEY POINT: The RN, determines the appropriate match between the patient and BHT or BHA, and assigns a task to the BHT or BHA based on their competency and job description. If a BHT or BHA does not perform their assigned task, the RN is NOT held responsible. -
Nurse Life Care Plan for (Client) - Table of Contents
NURSE LIFE CARE PLAN for (Client) ©2011, Shelene Giles Methodology The American Nurses Association (ANA) defines nursing as the protection, promotion, and optimization of health and abilities; prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations. The human response includes the response of the individual and family to actual or potential health problems. ANA notes “…Nurses are educated to be attuned to the whole person, not just the unique presenting health problem. While a medical diagnosis of an illness may be fairly circumscribed, the human response to a health problem may be much more fluid and variable and may have a great effect on the individual’s ability to overcome the initial medical problem. In what some describe as a blend of physiology and psychology, nurses build on their understanding of the disease and illness process to promote the restoration and maintenance of health in their clients…Nursing is a key element in patient survival as well as in the maintenance, rehabilitation, and preventive aspects of healthcare.." (ANA Nursing's Social Policy Statement, Second Edition, 2003). The American Association of Nurse Life Care Planners (AANLCP) defines nurse life care planning as utilizing the nursing process in the collection and analysis of comprehensive client specific data in the preparation of a dynamic document. This document provides an organized, concise plan of estimated reasonable and necessary, current and future healthcare needs with the associated costs and frequencies of goods and services. The Nurse Life Care Plan is developed for individuals who have experienced an injury or have chronic healthcare issues. -
Nursing Documentation in Clinical Practice
From the Department of Nursing, Karolinska Institutet, Stockholm, Sweden Nursing Documentation in Clinical Practice Instrument development and evaluation of a comprehensive intervention programme Catrin Björvell Stockholm 2002 Nursing Documentation in Clinical Practice Instrument development and effects of a comprehensive education programme By: Catrin Björvell Cover layout: Tommy Säflund Printed at: ReproPrint AB, Stockholm ISBN 91-7349-297-3 NURSING DOCUMENTATION IN CLINICAL PRACTICE There is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle than to initiate a new order of thing. Machiavelli, The Prince Nursing documentation in clinical practice Instrument development and evaluation of a comprehensive intervention programme Catrin Björvell, Department of Nursing, Karolinska Institutet, Stockholm, Sweden Abstract The purpose of this study was to describe and analyse effects of a two-year comprehensive intervention concerning nursing documentation in patient records when using the VIPS model - a model designed to structure nursing documentation. Registered Nurses (RNs) from three acute care hospital wards participated in a two-year intervention programme, in addition, a fourth ward was used for comparison. The intervention consisted of education about nursing documentation in accordance with the VIPS model and organisational changes. To evaluate effects of the intervention patient records (n=269) were audited on three occasions: before the intervention, immediately after the intervention and three years after the intervention. For this purpose, a patient record audit instrument, the Cat-ch-Ing, was constructed and tested. The instrument aims at measuring both quantitatively and qualitatively to what extent the content of the nursing process is documented in the patient record. -
Barriers to Implementation of Nursing Process Among Nurses Working in Narok County Referral Hospital
BARRIERS TO IMPLEMENTATION OF NURSING PROCESS AMONG NURSES WORKING IN NAROK COUNTY REFERRAL HOSPITAL LEKENIT SARETIN ANNA A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE CONFERMENT OF DEGREE OF MASTER OF SCIENCE IN NURSING EDUCATION OF KENYA METHODIST UNIVERSITY OCTOBER 2020 DECLARATION ii DEDICATION This research is dedicated to all nurses in Narok County both private and public sector. iii ACKNOWLEDGEMENT God almighty, receive glory and Honour for having given me good health, finances and time during the entire period of my research project development. I also acknowledge my research supervisors Prof. Ruth Gathigia Gatere and Dr. Agnes Mutinda Kasusu for their guidance and advice. Lastly, I sincerely recognize my Husband Mr. Murrey, my daughter Muriel, my sister Alison and my entire family for their time, contribution and input towards my research project. iv ABSTRACT Globally, nursing process has gained popularity and is utilized in hospitals to offer quality individual nursing care to patients. It is utilized by nurses in clinical setup to offer quality nursing care to patients individually as unique and having special needs. Nursing process non-implementation can lead to poor nursing care to patients in healthcare institutions. This study therefore assessed barriers of nursing process implementation by Narok County Referral Hospital (NCRH) nurses. A descriptive cross sectional study design was used to collect data from 102 conveniently sampled nurses in NCRH. The study instruments used were self-administered questionnaires and key informant interview. SPSS version 20.0 was used to analyze quantitative data and sample characteristics were analyzed using mean and median. Qualitative data was thematically analyzed and presented in tables. -
The Benefits of Using Standardized Nursing Terminology
Page 1 of 20 Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care By Cynthia B. Lundberg, R.N., BSN; SNOMED Terminology Solutions; Judith J. Warren, PhD, RN, BC, FAAN, FACMI; University of Kansas; Jane Brokel, PhD, RN, NANDA International; Gloria M. Bulechek, PhD, RN, FAAN; Nursing Interventions Classification; Howard K. Butcher, PhD, RN, APRN, BC; Nursing Interventions Classification; Joanne McCloskey Dochterman, PhD, RN, FAAN; Nursing Interventions Classification; Marion Johnson, PhD, RN; Nursing Outcomes Classification; Meridean Maas PhD, RN; Nursing Outcomes Classification; Karen S. Martin, RN, NSN, FAAN; Omaha System; Sue Moorhead PhD, RN, Nursing Outcomes Classification; Christine Spisla, RN, MSN; SNOMED Terminology Solutions; Elizabeth Swanson, PhD, RN; Nursing Outcomes Classification, Sharon Giarrizzo-Wilson, RN, BSN/MS, CNOR, Association of PeriOperative Registered Nurses Citation: Lundberg, C., Warren, J.., Brokel, J., Bulechek, G., Butcher, H., McCloskey Dochterman, J., Johnson, M., Mass, M., Martin, K., Moorhead, S., Spisla, C., Swanson, E., & Giarrizzo-Wilson, S. (June, 2008). Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care. Online Journal of Nursing Informatics (OJNI), 12, (2). Available at http:ojni.org/12_2/lundberg.pdf Page 2 of 20 Abstract Using standardized terminology within electronic health records is critical for nurses to communicate their impact on patient care to the multidisciplinary team. The universal requirement for quality patient care, internal control, efficiency and cost containment, has made it imperative to express nursing knowledge in a meaningful way that can be shared across disciplines and care settings. The documentation of nursing care, using an electronic health record, demonstrates the impact of nursing care on patient care and validates the significance of nursing practice. -
The Right to Get Good Nursing Care
THE RIGHT TO GET GOOD NURSING CARE Babone, Kofi 2009 Otaniemi Laurea University of Applied Sciences Otaniemi THE RIGHT TO GET GOOD NURSING CARE Kofi Babone Degree programme in nursing Thesis March, 2009 2 Laurea University of Applied Sciences ABSTRACT Otaniemi Degree programme in Nursing Kofi Babone The right to get good nursing care Year 2009 Pages 47 The purpose of this thesis is to find out nurses’ descriptions of the implementation of the act of the patient rights with pulmonary disease in HUS Jorvi hospital and how the nurses implement the act of the patient rights in their own ward. This thesis aimed at collecting data from nurses at a hospital ward. The research ques- tions are: What are pulmonary patients’ rights according to the act described by nurses and how do nurses implement the patient rights in their own ward. The method of qualitative nursing research was conducted in this thesis. Focus group interviewing was the research method. The informants (n = 5) of this thesis were regis- tered nurses. They worked on a pulmonary ward in HUS Jorvi hospital, Espoo, Finland. The interview was implemented in December 2008. The collected data was analysed by using inductive content analysis. In this thesis the findings propose that the funda- mental rights of the patients on pulmonary ward are individuality, co-operation and nursing, which have sub-categories of equality, needs, privacy, information, decision- making, opinions, primary nursing, delicate nursing and specialised nursing. As a unit- ing category to all these rights was the right to get good nursing care. The implementa- tion of these rights on pulmonary ward complied relatively well with the views of the nurses. -
An Exploration of the Nursing Role in a Telehealth Based Stroke Secondary Prevention Program
NURSE – LED TELEHEALTH STROKE PREVENTION 1 An Exploration of the Nursing Role in a Telehealth Based Stroke Secondary Prevention Program. Submitted in total fulfilment of the requirements of the degree of Master of Philosophy. April 2015 David A. G. Jackson. Department of Medicine and Health Sciences. School of Nursing. The University of Melbourne. Correspondence concerning this work should be addressed to David Jackson, Department of Neurology, The Royal Melbourne Hospital, Grattan St Parkville, Victoria 3050. Produced on archival quality paper NURSE – LED TELEHEALTH STROKE PREVENTION 2 Abstract This research study set out to explore a specialist nursing role in the field of Telehealth for chronic disease management. This study aimed to explore the role of the nurse through measurement of nursing activity during the one-year period of participant follow-up. The study aimed to effect long-term secondary prevention of stroke through an evidence based approach to the management of modifiable cardiovascular risk factors and post stroke depression in the community setting. Research suggests that up to 80% reduction of risk of successive stroke can be achieved if recommendations from evidence-based guidelines are implemented. Notwithstanding these findings a gap exists in the implementation of preventative strategies for stroke survivors in the community. Results from previous research indicate that Telehealth is cost effective and potentially may significantly reduce socioeconomic burden and the probability of successive stroke. A small number of studies have highlighted potential mechanisms through which Telehealth can benefit the stroke survivor, carers, families and health professionals. Researchers have recommended more research into Telehealth in order to develop and to define effective interventions. -
Perceptions of Nursing Care for Cardiovascular Cases, Knowledge on the Telehealth and Telecardiology in Indonesia
Perceptions of Nursing Care for Cardiovascular Cases, Knowledge on the Telehealth and Telecardiology in Indonesia Rr. Tutik Sri Hariyati, Junaiti Sahar International Journal of Collaborative Research on Internal Medicine & Public Health Vol. 4 No. 2 (February 2012) International Journal of Collaborative Research on Internal Medicine & Public Health (IJCRIMPH) ISSN 1840-4529 | Journal Type: Open Access | Volume 4 Number 2 Journal details including published articles and guidelines for authors can be found at: http://www.iomcworld.com/ijcrimph/ To cite this Article: Hariyati RTS, Sahar J. Perceptions of Nursing Care for Cardiovascular Cases, Knowledge on the Telehealth and Telecardiology in Indonesia. International Journal of Collaborative Research on Internal Medicine & Public Health . 2012; 4(2):116-128. Article URL: http://iomcworld.com/ijcrimph/ijcrimph-v04-n02-04.htm Correspondence concerning this article should be addressed to Rr. Tutik Sri Hariyati; Faculty of Nursing, University of Indonesia, Indonesia | Email: [email protected], [email protected] Paper publication: 07 February 2012 116 International Journal of Collaborative Research on Internal Medicine & Public Health Perceptions of Nursing Care for Cardiovascular Cases, Knowledge on the Telehealth and Telecardiology in Indonesia Rr. Tutik Sri Hariyati *, Junaiti Sahar Faculty of Nursing, University of Indonesia, Indonesia * Corresponding Author ABSTRACT Background: Nowadays, the life-style displacement promotes the increasing of degenerative disease, such as cardiovascular disease, which since 1995, has been stated as the main cause of fatality in Indonesia. Telehealth was defined as the use of the telecommunication technology to support the health information and increase the health service. Telehealth in developed countries can improve the behavior of healthy living. -
Standard Nursing Terminologies: a Landscape Analysis
Standard Nursing Terminologies: A Landscape Analysis MBL Technologies, Clinovations, Contract # GS35F0475X Task Order # HHSP2332015004726 May 15, 2017 Table of Contents I. Introduction ....................................................................................................... 4 II. Background ........................................................................................................ 4 III. Landscape Analysis Approach ............................................................................. 6 IV. Summary of Background Data ............................................................................ 7 V. Findings.............................................................................................................. 8 A. Reference Terminologies .....................................................................................................8 1. SNOMED CT ................................................................................................................................... 8 2. Logical Observation Identifiers Names and Codes (LOINC) ........................................................ 10 B. Interface Terminologies .................................................................................................... 11 1. Clinical Care Classification (CCC) System .................................................................................... 11 2. International Classification for Nursing Practice (ICNP) ............................................................. 12 3. NANDA International -
Practice Directive Documentation Standards
Practice Directive Documentation Standards College of Registered Nurses of Prince Edward Island December 2020 Approved by CRNPEI Council Dec 10, 2020 Introduction The College of Registered Nurses of Prince Edward Island (CRNPEI) and the College of Licensed Practical Nurses of Prince Edward Island (CLPNPEI) are legislated to serve and protect the public interest through the regulation of individual registered nurses (RN), nurse practitioners (NP) and licensed practical nurses (LPN). For the purposes of this document the term nurse(s), will refer to all three designations of nurses in Prince Edward Island. Nurses in Prince Edward Island are accountable to practice within their Code of Ethics, Standards of Practice, and to meet established agency practice policies and procedures. As self-regulating professions, Nurses are regulated under the authority of the Prince Edward Island Regulated Health Professions Act (2013) and corresponding regulations, which outline the accountabilities and responsibilities of Nurses. This includes a Nurses’ legal responsibility to practice within their scope of practice and level of competence. Nurses must know what they are authorized and competent to perform, including any limitations in skill, knowledge, and judgement to ensure their practice is within their scope. Nursing documentation is a vital component of safe, ethical and effective nursing practice, regardless of the context of practice or whether the documentation is paper- based or electronic. Purpose The purpose of this practice directive is to set a standard for how nurses should document within their practice while remaining accountable to the CRNPEI Standards of Practice, and the Regulated Health Professions Act (RHPA). This document describes nurses’ accountability and the expectations for documentation in all practice settings, regardless of the documentation method or storage. -
Lander University School of Nursing Policy and Procedure Manual 2019
LANDER UNIVERSITY SCHOOL OF NURSING POLICY AND PROCEDURE MANUAL 2019-2020 (Revised SPRING 2019) Nursing Policy and Procedure Manual Attestation Statement As part of professional accountability in nursing, all students (prelicensure and RN-BSN) are expected to read the Nursing Policy and Procedure Manual each fall and spring semesters. Students are expected to read the entire manual upon admission to provisional status. Students are responsible for the content in the manual and for adherence to policies of the School of Nursing. Any questions regarding policies should be referred to the student’s assigned academic advisor. May 2014; 5/2015; 5/2016; 5/2017; 5/2018 My signature indicates my understanding and agreement with the above statement. Sign_________________________________ Print________________________________ Date________________________________ Upon receipt of this manual, tear out this form and turn in to the Dean of the School of Nursing. i TABLE OF CONTENTS I. PHILOSOPHY AND CURRICULUM Part A: Philosophy……………………………………………………………………………………………………….. 1 History……………………………………………………………………………………………………………………………… 1 Accreditation…………………………………………………………………………………………………………………….1 Curriculum Philosophy………………………………………………………………………………………………………1 Mission Statement…………………………………………………………………………………………………………… 2 Philosophy and Core Values…………………………………………………………………………………………….. 2 Vision………………………………………………………………………………………………………………………………. 3 Standards of Practice……………………………………………………………………………………………………….. 3 Nursing Conceptual Framework………………………………………………………………………………………. -
Essential Elements of Nursing Notes and the Transition to Electronic Health Records
FEATURE: NURSING Essential Elements of Nursing Notes and the Transition to Electronic Health Records The Migration from Narrative Charting Will Require Creativity to Include Essential Elements in EHRs. By Marjorie M. Heinzer, PhD, PNP-BC, CRNP urses have told the patient’s story for KEYWords decades in the form of written narrative Charting, documentation, nursing care, computerization, nursing notes and the verbal shift report. electronic health record, EHR. N The advent of paper flow sheets and checklists over Abstract the past two decades streamlined the data record- Nursing notes have historically told the patient’s story of ing process for many specialty and acute-care nursing care during a hospital stay, but technology and units. However, improvements in computer tech- trends in healthcare require conversion of paper to electronic nology now support the implementation of clinical health records (EHR). The purpose of this study was to explore what clinical nurses believe are essential elements documentation and information systems across of nursing notes, ways that these data are documented and all healthcare disciplines. This move to computer- barriers to documentation. ized systems makes it necessary for nursing and This qualitative study used four focus groups. Twenty-four allied health professionals to reframe their think- registered nurses identified themes of evidence of care, quality issues, interaction patterns, clarification and the ing about recording the patient’s story. Commonly “picture” of the patient. held beliefs among some nurses, as explored in this Barriers to documentation were time, legal issues, study, are the need to tell the patient’s story, explain defensive charting, “sidebars” and family/patient behavior.