Nursing Documentation In Nursing

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The purpose of this study is to identify the completeness of nursing documentation of data collected on patient history and nursing assessment during the first 24 hours of admission. These results consent identifying the efficacy of nursing records to convey information about care delivery to patients and problems, granting the team at this teaching hospital knowledge on all events. To live up to the expectations of the general public, nurses are expected to fully comprehend the duties associated with their position as set forth by the governing bodies, but also the institutional policies and procedures affecting their practice. One particular duty that deserves significant emphasis is the requirement of complete and accurate documentation which provides a clear picture of the patient while under the care of the health care team. The aim of nursing documentation is to register information on care delivery, to guarantee communication among health team members and permit the continuity of the multiprofessional work process, guaranteeing security to patients and support from the legal and ethical viewpoints. Nursing documentation is defined as the record of nursing care that is planned and given to individual patients and clients by qualified…show more content…
One such standard is the style of documentation at the University Hospital of the West Indies. According to the University hospital of the West Indies policy manual nurses are required to use the ADPIE method when documenting patient care. The results of this revealed that 50% of the dockets audited used the head to toe method in comparison to 39.5%, 34.4% and 25.6% who use the checklist, systemic and focus methods respectively. Of the 220 dockets audited there was no evidence of the recommended style of documentation namely, the ADPIE

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