Reflection in documentation

п»їREFLECTION UPON DOCUMENTATION ANALYSIS EXPERIENCE

I've come to find out that paperwork is an important part of nursing practice, in the specialized medical setting (Perry & Potter, 2014). Among the fundamental aspires for healthcare professionals in all areas is to secure the well being of their individuals through right documentation ((Nursing and Midwifery Board of Australia -- Codes and Guidelines, and. d). This can be achieved by applying and maintaining good documents practice through progress remarks writing in every healthcare department specifically nursing (Miller & Cameron, 2011). In this briefing essay am going to provide an insight into the benefits of correct documentation in nursing and i also will spotlight the areas needing development the moment writing my progress remarks. The quality of attention a patient receives relies heavily on suitable and correct connection through paperwork (Patient Progress Note & Dictation Normal, n. d. ). I've learnt to document data that is specific to the sufferer through keeping away from generalising transactions like " observations between the flags” instead; I should record information that is specific to the patient. Consequently, am carrying on to practice appropriate documentation particularly by providing very clear records that may allow different health care specialists to provide appropriate and regular care for the person hence steering clear of miscommunications (Nursing and Midwifery Board of Australia - Codes and Guidelines, and. d). I possess also discovered to put into practice appropriate and effective methods when recording through next Information, Situation, Background, Analysis, Recommendation (ISBAR) in a comprehensive mode (Nursing and Midwifery Board of Australia -- Codes and Guidelines, in. d. ). ISBAR gives a systematic framework in manifestation professional and quality medical care as well as the integral area of the nursing practice. Thus, I am continue to learning to record with utmost attention and practice in the clinical placing (Nursing and Midwifery Table of...

References: Carpenito, В L. В J. (2009). В Nursing treatment plans & documentation: Medical diagnoses and collaborative concerns. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Lippincott Williams & Wilkins. (2011). В Chart Intelligent: The A-to-Z guide to better nursing documentation. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Nursing and Midwifery Table of Sydney - Codes and Suggestions. (n. m. ). RetrievedВ MayВ 17, 2015, coming from http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx#competencystandard

Perry, В A. В G., Potter, В P. В A., & Ostendorf, В W. (2014). В Clinical nursing skills & techniques. St . Paillette, MO: Mosby/Elsevier.

Patient Improvement Note & Dictation Normal. (n. g. ). RetrievedВ MayВ 17, 2015, coming from http://bphc.hrsa.gov/archive/technicalassistance/resourcecenter/services/patientprogressnoteprotocol.pdf

WACHS Allied Wellness Assistant Teaching Mini-Module Documentation. (n. g. ). RetrievedВ MayВ 17, 2015, via http://www.wacountry.health.wa.gov.au/fileadmin/sections/allied_health/WACHS_G_AHA_TrainingMini-Module.pdf

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