...Practice Evidence based interventions are playing an increasingly more important role in nursing practice. With the increased utilization of nursing research comes a need for a form of communication that classifies diagnosis, applies interventions, and expected patient outcomes. In order to unify nursing communication and support nursing practice, standardized terminology has been developed. This paper will introduce three forms of standardized terminologies in nursing which are the North American Nursing Diagnosis Association (NANDA), Nursing Outcome Classification (NOC), and Nursing Intervention Classification (NIC). The purpose of this paper is to define the three standardized terminologies, processes developed, and to provide and example of their useful application in patients at risk for or diagnosed with pressure ulcers. The NANDA was established with the goal of enhancing all aspects of nursing practice by refining and promoting terminology to accurately reflect the clinical judgment of nurses (Azzolin et al., 2013). The mission of NANDA if to facilitate the refinement, dissemination, and development, and utilization of nursing standard terminology (Peres et al., 2015). Their main focus is to utilize this communication to promote evidence based practice and care, thereby improving care for everyone. NANDA promotes their missions and goals by publishing the world leading evidence based nursing diagnosis, funding research, establishing a global nursing network, and integrating...
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...Identification of the educational need and rationale: The implementation of electronic documentation for medical records, medications, and nursing flow sheets has replaced the existing paper documentation and is currently the educational need with the highest priority for the Emergency Department at the University of Massachusetts Memorial Medical Center. In a continuous care operation, it is critical to document each patient’s condition and history of care, to ensure the patient receives the best available care. The medical record documents the care of the patient and can immediately be accessed, updated, and passed among the interdisciplinary team of caregivers. The Emergency Department is the initial passageway to the hospital for most patients. Electronic documentation is a patient’s health information including medications, allergies, past and present illnesses, and family history can be gathered upon their initial presentation and up-to-the minute revisions can be made by the healthcare team throughout their hospital stay. The Electronic Medical Record/Charting can be designed to hold collaborative information from all providers that are involved in the patients’ care. With each subsequent visit thereafter, the patient’s demographic, insurance, and health history database will automatically pre-fill the electronic template alleviating nurses of time restraints associated with paper documentation. This allows for quick updates to the patient’s profile if necessary. Patients...
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...Electronic Documentation Nursing is a fast changing profession that has been vital to providing care in the medical setting. Throughout the past several years one of the most recognizable changes in the medical field is the transformation from paper charting to electronic forms of documentation. This has led to a decrease in the amount of paper charting by allowing nurses to use check boxes, cell formatting, and computer databases to keep patients records more accessible and organized. As new forms of technology become available we find that there are often flaws that need to be assessed and corrected to properly implement an optimal computing system. The clinical integration paper examines the positive and negative aspects of electronic documentation in the nursing field as it pertains to time management, patient safety and its efficacy. It was found that nurses spend the largest proportion of their time at the nurses station documenting and coordinating patient’s care with twenty five to fifty percent, which results in less time spent on patient care (Blair & Smith, 2012). This is alarming knowing that approximately a quarter to half of a nurse’s shift is done sitting in front of a computer documenting the day’s events. At Central Baptist Hospital I believe that more than half a day could be taken up by computer charting. From what I have experienced, a nurse may begin their shift with anywhere between four to six patients. These patients require a general...
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...“The nursing process is essentially a problem-solving process” (Treas & Wilkinson, 2014, p. 31). It is a standardized way of getting information about the patient to best treat them and then evaluating what you have done. All steps of the nursing process are evident in the electronic health record (EHR), they however are not necessarily next to each other in the order of the nursing process as explained in a nursing textbook. It depends on the format of the EHR that is chosen by your place of employment. “Regardless of the type of documentation that is used, you will use or refer to the nursing process as a guideline when you are charting” (Treas & Wilkinson, 2014, p. 390). There are narrative formats to use when charting in source-orientated...
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...Negligence Paper University of Phoenix Health Law & Ethics Negligence Paper Being a medical professional has many challenges when dealing with direct patient care. Sometimes in the best of circumstances, incidents occur with patients that cause undue harm. This paper will differentiate between negligence, gross negligence, and malpractice. It will also discuss the article “Amputation Mishap; Negligence” from the Neighborhood newspaper. It will discuss the importance of documentation and the ethical principles that would guide my practice as a nurse. Negligence can be defined as the failure to use reasonable care that a reasonably prudent person would exercise in like circumstances. (West, 1998). Negligence occurs when a medical health professional fails to perform his or her duties with the patient in question. If a nurse fails to give medications as ordered, and as a result the patient's condition worsens or he dies, the nurse may be found negligent. If a nurse has inadequate nursing skills or fails to pay attention to tasks, it may result in a suit of negligence against a nurse who fails to provide approved standards of care. A good nurse knows their duties and has good communication between the patient and the physician. The nurse knows board regulations and practices within legal guidelines. Gross negligence can be defined as a conscious and voluntary disregard of the need to use reasonable care which is likely to cause foreseeable grave injury or...
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...anticipated to grant benefits during a practically extended, usually a minimum two years, sometimes longer (Cleverley & Cameron, 2007). Client Health and Rehabilitation Center a skilled nursing facility in Anywhere, NY has determined that a capital expenditure of an installation of electronic medical records (EMR) will help their facility compete with surrounding facilities. The cost will be roughly $50,000, and will consist of the hardware, labor, software, service, and education for facility staff. This paper will confer that attainment of electronic medical record hardware and software will facilitate organizational and management with facility goals based on the necessity of the facility to compete with other facilities in the area that are technically advanced. In the long run the facility will reap the rewards of the installation of this new technology. Management Goals Productivity The chief goals of the administration group at Client Health and Rehabilitation Center is that of productivity. With the organization becoming further advanced technologically owing to the use of the EMR system, responsibilities that consist of procuring doctors orders for updating, filing, and charting additional redundancies, and use many paper charts will not be necessary, thereby doing away this outdated responsibility. Acquiring information for chart audits to determine code status, new doctor orders, and accurateness of assessments...
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...advocating health to increase the chance that personal, private , and public support of positive health practices will become a societal norm” (Kreuter & Devore, 1980, p. 26). Despite the variances in definition health promotion is geared towards persuading public the benefits of a living a lifestyle free of negative health behaviors. The purpose of health promotion in nursing practice is to switch gears from protection of certain diseases to focus on improving the general health of the people they serve. Health promotion has changed the roles and responsibilities of nurses. Increasing demands are placed on nurses as healthcare has shifted from an acute, hospital-based care to preventive, community-based care. The home is now the primary place healthcare takes place. Reimbursement for hospital care is less resulting in shorter stays. Nurses must take on additional roles and play a bigger part of disease prevention and health promotion. A greater emphasis is being placed on nurses being more independent in their practice. Nurses are expected to be increasingly accountable morally and legally for their behavior. Nursing has evolved into many roles as advocates, care managers, consultants, delivery of services, educators, and healers. As advocates a nurses strives to ensure the patient receives the high quality, best care in a cost effective manner. In the role of a case manager the nurse strives to maintain continuity of care, prevent ineffective or unsafe care, and service duplication...
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...EMORY UNIVERSITY NELL HODGSON WOODRUFF SCHOOL OF NURSING TITLE: NRSG 507: Theory and Research Applications CREDIT ALLOCATION: 3 Semester hours PLACEMENT: Tuesdays 1:00 – 3:50 PM Rm. 201 FACULTY: Catherine Vena, PhD, RN | Eun Seok (Julie) Cha, PhD, RN | Clinical Associate Professor | Assistant Professor | Room 224 | Room 234 | cvena@emory.edu | echa5@emory.edu | 404-727-8430 | 404-712-9578 | Office Hours: By appointment | Office Hours: By appointment | COURSE DESCRIPTION: This course is an introduction to the theoretical and research foundations of advanced nursing practice. Key content to be covered includes the philosophical basis of science and knowledge, the structure and development of theory, qualitative and quantitative research methods, theory and research critique, and the application of theory and research in advanced nursing practice. It delineates research competencies for advanced practice nurses. The course encompasses critique of studies, application of research findings to practice (research utilization) and evaluation of outcomes attributable to advanced practice nursing. Ethical considerations related to research are integrated throughout the course. COURSE OBJECTIVES/OUTCOMES: 1. Understand the relationship between theory, research, and practice. 2. Critique and evaluate theoretical perspectives and research methods used to address clinical problems. 3. Understand...
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...Resistance of Nurses in Use of Electronic Documentation The field of health information technology for nursing is rapidly growing. Advancements in electronic documentation for health care, such as the electronic medical record (EMR), can be an overwhelming addition to the workload of nurses. There is resistance by nurses in use of electronic documentation (Sharifian, Askarian, Nematolahi, & Farhadi, 2014). It is this writer’s opinion that nurses are under informed regarding the rationale for changes taking place in documentation and the implications. The purpose of this paper is to provide nurses with the basics of the Federal regulations outlined in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) that require electronic documentation to be compliant and receive reimbursement. It also reviews how data are collected to determine the reimbursement for care (meaningful-use) and its role in evidence-based practice (Wright, Feblowitz, Samal, McCoy, & Sittig, 2014). Included is a review of the negative impact resistance generates on health organization reimbursement and the relevance it has on nurse staffing, jobs, wages, and satisfaction, along with, evidence reinforcing the training and support of nurses as a means to promote proper use of electronic documentation and increase user satisfaction. Federal Laws and Requirements for Compliance Health care...
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...Effective Approaches in Leadership and Management (Benc Grand Canyon University: NRS 451V June 4, 2016 NRS451V Nursing Leadership and Management 6/4/16 Very good work on this paper. Well written and your thoughts transitioned easily from one point to the next. Your comparison/contrast of leadership styles and your description of your preferred style was very good. However, there were numerous errors in documentation of your sources. I strongly encourage you to go to the Purdue Online Writing Lab site http://owl.english.purdue.edu/owl/resource/560/01/ or the word document that I provided for the class for correct formatting for your paper, in-text citations, and Reference page documentation. Note the corrections to your header section, throughout the body of the paper, and on your Reference page. Note the grammar/punctuation corrections (I did provide instructions on setting up your word document to check for grammar/punctuation when you perform spelling check; it is in the week 1 resources). Additionally, this paper was to have been a Maximum of 1250 words in length – your paper (before my corrections and allowable overage of 125 words) was 1424 words. A deduction in grade was applied for being over the maximum word count allowed. Effective Approaches in Leadership and Management Introduction The introduction of the bargain basement pattern of care has completely transforms the way healthcare system is operating at the present time. With healthcare plan being changed...
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...An Ethical Analysis of Negligence In this paper, the author will describe the main differences among negligence, gross negligence, and malpractice in the medical field. In addition, the author will explain his opinion about this article and the facts described in it as well as the rationale used to form this opinion. Furthermore, the author will describe the importance of documentation in the medical field as well as how nurses should document when providing care while complying with legal and ethical requirements. Unintentional torts are the most common torts in the medical field. Torts are acts occurred without the tortfeasor intention to cause harm; however, some type of harm results from it. Torts are also actions committed unreasonably or disregarding the consequences, in legal terms this represents negligence (Judson & Harrison, 2010). According to Judson and Harrison (2010), negligence is an unintentional tort and a person is negligent when in similar circumstances he or she did not performed as expected from a reasonable person (Judson & Harrison, 2010). Defining gross negligence is a more complicated issue. According to Thornton (2006) the Texas Civil Practice and Remedies Code defines gross negligence as an act of omission that when viewed from the position of the actor at the time the omission occurred it shows a significant degree of risk and possible harm to others (Thornton, 2006). In addition, the actor is aware of the risks but proceeds disregarding the rights...
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...NURSING INFORMATICS LEADERSHIP Evaluation of Computerized Management Systems Kathryn Rawson Western Governors University Abstract This paper will demonstrate: A. How using computerized management systems could increase quality of care B. Why active nursing involvement in the planning, choice and implementation of the systems is important C. How handheld devices used by the nursing staff could be integrated into the management system for better quality care D. Security standards of data and patient confidentiality, including the need for data storage integrity and data backup and recovery and the Health Insurance Portability and Accountability Act (HIPPA) requirements impact the use of the systems E. How the new system can affect healthcare cost F. The benefits these new systems can offer to patient care and nursing care delivery with a recommendation and justification of the system the hospital should put in place In today’s modern healthcare environment it is important to provide a variety of technology based resources to nurses and other providers to ensure productivity and efficiency are maximized. This requires an effective understanding of available computerized management systems and what resources are available to ensure continued effective, efficient, quality care to patients. Keeping that perspective in mind while creating a technologically advanced environment in which to deliver that care is critical and of vital importance to...
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...patient centred care possible. Code 22.3 of the Nursing and Midwifery Council (NMC) code of conduct (2015) refers to the need for midwives and nurses to keep their skills and knowledge up to date,...
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...Changing Paper Documentation to Electronic in Healthcare Name Institution Date Introduction Changing from paper documentation to electronic documentation is just like switching from analog to digital television. Rigidity in institutions may prevail but at the end all the institutions conform to one documentation method the electronic documentation. An electronic document is any media content other than computer system files or programs used in either soft copy form or paper as a print out (Yu, 2006). With technological advancement, the use of written documents has reduced because it has become easier to distribute and display documents in screens (AWARE, 2005). The method has an impact on reducing paperwork and space for storage of these materials. Documentation of activities involving purchases, sales, distribution, drug administration, patient health record, finance and other relevant activities of any organization is a primary issue in maintaining efficiency in operations (AHIMA, 2010). The use of paper documentation is somehow a far behind the method and rather tedious and inefficient. A more reliable and efficient way of keeping health records is thus a necessary change that may help reduce the demerits associated with the paper documentation method. Technologically advancement has brought with it more efficient and easy way to record and maintain a company or organization’s documents (AWARE, 2005). Changing from paper to electronic file documentation is thus a primary...
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...Adolescent or Young Adult Client" worksheet. Format the write-up in a manner that is easily read, computer-generated, neat, and without spelling errors. Complete the assignment as outlined on the worksheet, including: 1. Biographical Data 2. Past Health History 3. Family History: Obstetrics History (if applicable) and Well Young Adult Behavioral Health History Screening 4. Review of Systems 5. Include all components of the health history 6. Use correct acronyms or abbreviations when indicated 7. Develop three Nursing Diagnoses for this client based on the health history and screening. Include: one actual nursing diagnosis, one wellness nursing diagnosis, one "Risk For" nursing diagnosis, and your rationale for the choice of each nursing diagnosis for this client. While APA format is not required for the body of this assignment, solid academic writing is expected and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center. This assignment uses a grading rubric. Instructors will be using the rubric to grade the assignment; therefore, students should review the rubric prior to beginning the assignment to become familiar with the assignment criteria and expectations for successful completion of the assignment. No, you don't need to...
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