Question

  Module 02 Discussion - Documentation and Informatics

After reading the chapter in your textbook, focus on documentation and informatics. Think about the principles of reporting and documentation. Identify and briefly discuss three challenges a nurse has in ensuring accurate and confidential documentation. Then discuss what actions a nurse can take to overcome these challenges including how informatics might make a difference.

Answer 1

Three challenges in nursing documentation

            1. Documentation errors.

             2. Entering personal opinions in documentation.

             3. Another person or health care provider know about your computer password when

             using EHR (Electronic health record) for documentation.

Actions needed to overcome this challenges

            1. Documentation errors

                                * Rechecking of all patient reports after documentation.

                                * Complete charting of patient details only after ensuring informations are

                                   accurate and complete.

          2. Entering personal opinions in documentation

                                 * Avoid use of subjective statements when documenting patient health information.

                                 * Documentation should be objective and factual informations of patient condition.

                                 * Documentation should be evidence based and do not use our thoughts about

                                    patients in patient chart.

         3. Another person know about our password in EHR

                                  * To maintain security and confidentiality in records nurse should keep the

                                      password informations confidentially .

                                  * Do not leave computer screen unattended after logged into computer.

                                  * Ensure that computer information of health care providers not accessible

                                    to public.

     Effect of informatics in nursing documentation

                                   * It help to maintain the privacy of patient data by using passwords to

                                      protect patient information.

                                   * It make the therapeutic communication between the physician and nurses

                                     become easy.

                                   * Nurses and other health providers can use computer patient informations as

                                     a legal document.

                                  * It helps the nurses to save time in recording of patient data and spend more

                                     time in patient care.