Improving Nursing Documentation And Reducing Risk
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Improving Nursing Documentation And Reducing Risk
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Author : Patricia A. Duclos-Miller
language : en
Publisher:
Release Date : 2016
Improving Nursing Documentation And Reducing Risk written by Patricia A. Duclos-Miller and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 2016 with HEALTH & FITNESS categories.
Improving Nursing Documentation And Reducing Risk
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Author : Patricia A. Duclos-Miller
language : en
Publisher:
Release Date : 2016-06-30
Improving Nursing Documentation And Reducing Risk written by Patricia A. Duclos-Miller and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 2016-06-30 with HEALTH & FITNESS categories.
Improving Nursing Documentation and Reducing Risk helps nurse managers create policies, processes, and ongoing auditing practices to ensure that complete and accurate documentation is implemented by their staff, without creating additional time burdens.
Clinical Documentation Strategies For Home Health
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Author : Elizabeth I Gonzalez, RN, Bs
language : en
Publisher: Hcpro, a Division of Simplify Compliance
Release Date : 2014-11-26
Clinical Documentation Strategies For Home Health written by Elizabeth I Gonzalez, RN, Bs and has been published by Hcpro, a Division of Simplify Compliance this book supported file pdf, txt, epub, kindle and other format this book has been release on 2014-11-26 with categories.
Clinical Documentation Strategies for Home HealthElizabeth I. Gonzalez, RN, BSN Are you looking for training assistance to help your homecare staff enhance their patient assessment documentation skills? Look no further than Clinical Documentation Strategies for Home Health. This go-to resource features home health clinical documentation strategies to help agencies provide quality patient care and easily achieve regulatory compliance by: Efficiently and effectively training staff to perform proper patient assessment documentation Helping nurses and clinicians understand the importance of accurate documentation to motivate improvement efforts Reducing reimbursement issues and liability risks to address financial and legal concerns This comprehensive resource covers everything homecare providers need to know regarding documentation best practices, including education for staff training, guidance for implementing accurate patient assessment documentation, tips to minimize legal risks, steps to develop foolproof auditing and documentation systems, and assistance with quality assurance and performance improvement (QAPI) management. Clinical Documentation Strategies for Home Health provides: Forms that break down the functions and documentation requirements of the clinical record by Conditions of Participation, Medicare, and PI activities Tips for coding OASIS Examples of legal issues such as negligence Case studies and advice for managing documentation risk (includes a checklist) Comprehensive documentation and auditing tools that can be downloaded and customized Table of Contents: Key aspects of documentation Defensive documentation: Reduce risk and culpability Contemporary nursing practice Clinical documentation Nursing negligence: Understanding your risks and culpability Improving your documentation Developing a foolproof documentation system Auditing your documentation system Telehealth and EHR in homecare Motivating yourself and others to document completely and accurately
Improving Nursing Documentation While Emphasizing The Importance Of Comprehensive Charting On The Removal Of Intravascular Devices
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Author : Carly Jane Wells
language : en
Publisher:
Release Date : 2017
Improving Nursing Documentation While Emphasizing The Importance Of Comprehensive Charting On The Removal Of Intravascular Devices written by Carly Jane Wells and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 2017 with categories.
Background: Healthcare documentation not only allows for communication among healthcare providers and maintains patient care record keeping, it also archives essential information used to track, evaluate, and consider valuable healthcare interventions. When documented properly, this information can be used in research to assess international and national healthcare topics like standards of care, quality of care, complication and infection rates, and many more. When documentation is not complete ad comprehensive, a false representation can be made and a patient's safety is at risk. The American Nurse Association suggests nursing documentation be clear, accurate, complete, and accessible, allowing nurses to be responsible and held accountable for their documentation. Foreground: The inpatient unit of interest for this project, like many other hospital units, demands several hours of direct patient care, potentially leaving little time for complete documentation. As a consequence, documenting on important aspects of a patient's record, like the removal of any intravenous device (IVD), are missed or incomplete. When these pieces of information are missing, opportunities to provide accurate data regarding patients, fall short. Therefore, it was this project's objective to influence staff nurses to be as comprehensive as possible when documenting overall, and to see an improvement on the removal of any IVD documentation after providing an educational in-service. Theoretical and EBP Support: Lewin's Change Theory served as a supporting component in influencing and guiding the nurses of interest, transforming their care and making it a standard of practice when documenting on the removal of IVDs. In supporting this project's development, the Johns Hopkins Nursing Evidence-Based-Practice (EBP) Model served as guiding feature in the specific steps of EBP in nursing. Methods: Once both Institutional Review Boards granted approval for this Quality Improvement project, chart audits were performed within a three-week time frame pre- and post- nurse in-service. The provided in-service was given to staff nurses, float pool nurses, and nursing students over an 11-day period. The in-service included pertinent aspects of documentation, steps to improve current practice, which was supported by current evidence, and time for discussion regarding potential barriers to complete documentation. Findings: A clinically significant improvement of 11% was seen in comprehensive documentation on the removal of IVDs on a specific surgical patient population. The findings of this project predictively aligned with literature that supports the use of health information technology, like the electronic health record, were data are accurately and efficiently collected, which can be used to generate knowledge that leads to improved outcomes. Although the practice improvement was seen in a limited amount of time, the direction was progressive, foretelling beneficial outcomes when these kinds of quality improvement projects are implemented.
Mastering Documentation
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Author : Springhouse Corporation
language : en
Publisher:
Release Date : 1995
Mastering Documentation written by Springhouse Corporation and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 1995 with Medical categories.
The complete guide for streamlining and improving nursing documentation for virtually every system. Nurses will find instructions for virtually every common and not-so-common charting method. From progress notes to protocols, there is a wealth of easy-to-follow examples throughout the book. Includes JCAHO-approved nursing abbreviations, ANA standards of practive, and JCAHO and Medicare guidelines for nursing documentation.
Managing Documentation Risk
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Author : Patricia A. Duclos-Miller
language : en
Publisher: HC Pro, Inc.
Release Date : 2004
Managing Documentation Risk written by Patricia A. Duclos-Miller and has been published by HC Pro, Inc. this book supported file pdf, txt, epub, kindle and other format this book has been release on 2004 with Medical categories.
Nurses are now commonly cited or implicated in medical malpractice cases.
Nursing Documentation
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Author : Patricia A. Duclos-Miller
language : en
Publisher: Hcpro, a Division of Simplify Compliance
Release Date : 2007
Nursing Documentation written by Patricia A. Duclos-Miller and has been published by Hcpro, a Division of Simplify Compliance this book supported file pdf, txt, epub, kindle and other format this book has been release on 2007 with Communication in nursing categories.
Written specifically for staff nurses, this easy-to-read and affordable resource helps nurses understand the value of good documentation, and the consequences of not documenting accurately and in a timely fashion. The handbook's case studies illustrate the legal threat nurses face from improper documentation, while the quick tips help them avoid common charting errors and improve their charting skills. Sold in packs of 25, the handbook includes a short post-test and certificate of completion, allowing nurses to evaluate their documentation understanding.
Nursing Compliance With Fall Risk Assessments
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Author : Karen Schilling Broderick
language : en
Publisher:
Release Date : 2017
Nursing Compliance With Fall Risk Assessments written by Karen Schilling Broderick and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 2017 with categories.
The purpose of the direct practice improvement project was to translate existing knowledge on fall prevention using education as the intervention to improve nursing compliance with risk assessing patients with the outcome of reducing patient falls. Two similar medical units in a large, inner city hospital were identified as having a high patient fall rate. Over a two-week time, 89 registered nurses were educated on fall prevention with an emphasis on the accuracy of a fall risk assessment, completion of nursing documentation in the electronic medical record, and the implementation of prevention interventions at the bedside. The American Association of Critical-Care Nurses' synergy model in collaboration with Lewin's theory of change was utilized as the framework for the project. A retrospective review of the patient falls for those units served as a baseline for the fall rate per 1000 patient days metric. A total of 83 medical records were reviewed 14 days post-intervention for nursing documentation along with real-time observation of the nursing practice on fall prevention (n = 83). The results, while not statistically significant, show slight percentage increases in nursing compliance with bed or chair alarm usage and purposeful rounding (p = .451). There was an overall reduction in patient falls for both units. Further sustainability of this project could lead to the ability to generalize to a larger population within the organization.
Quality Improvement An Issue Of Nursing Clinics
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Author : Treasa "Susie" Leming-Lee
language : en
Publisher: Elsevier Health Sciences
Release Date : 2019-02-06
Quality Improvement An Issue Of Nursing Clinics written by Treasa "Susie" Leming-Lee and has been published by Elsevier Health Sciences this book supported file pdf, txt, epub, kindle and other format this book has been release on 2019-02-06 with Medical categories.
With collaboration of Dr. Steve Krau, Consulting Editor, Drs. Leming-Lee and Watters have created an issue that provides state-of-the-art content on quality improvement. Top authors have contributed clinical reviews on the following topics: Quality improvement: Application of evidence-based practice; The application of the Virginia Mason production system to improve large scale quality outcomes in an acute care hospital; The application of the Toyota production system Lean 5S methodology in the operating room setting; Chart it to stop it: A quality improvement project to increase the reporting of workplace aggression; Reducing pressure injuries in the pediatric intensive care unit; Improving stress-induced hyperglycemic management in the ICU setting; Evaluation of telemetry utilization on medical-surgical floors; Implementation of a nurse-driven CAUTI prevention protocol; A quality improvement project to test the effectiveness of a patient-centered pathway and discharge tool on heart failure patient engagement; Diabetes self-management education provision by an interprofessional collaborative team: A quality improvement project; Increasing effective patient-triage nurse communication using a targeted history question; and Barriers to the implementation of pediatric overweight and obesity guidelines in a school-based health center. Nurses will come away with the current information they need to improve patient outcomes.
Documentation Skills For Quality Patient Care
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Author : Fay Yocum
language : en
Publisher:
Release Date : 1999
Documentation Skills For Quality Patient Care written by Fay Yocum and has been published by this book supported file pdf, txt, epub, kindle and other format this book has been release on 1999 with Medical categories.