Documentation vs Patient Care: Challenging but Essential

Lt. Col. Cissy Cruze, Nursing Director, Ruby Hall Clinic-

 

What are the challenges faced by the nurses in documentation?

 

In patient care documentation, the maximum work is done by the nurses. The issue is thereare no standardization for the documentation. There are repetitions. So a nurse has to do the maximum documentation. The reasons for her challenges are her levels because the attrition is so high. So we have level one, level two, level three nurses.  The primary role of the nurse is patient care but if documentation is not done that too is a challenge for her. If the principle of documentation is not recorded, it is considered as not done. With the attrition of nurse patient ratio, she will find it very hard since she has not had any basic education of this kind of documentation in her training. However, this has to continue and patients have to be cared for. The care for patients has to be documented. There are no two ways about it. So what are we here for? To overcome challenges and ensure that all the nurses are trained and helping them to balance the patient care as well as the documentation at the given period of time. That is what is expected of the leaders and that is what is expected of this quality.

Currently, there is no point in having excellence in pockets. Excellence is only when the whole country has the same standards of care. Be it private or be it public.

 

Dr Kashipa Harit, Deputy Diretor- NABH, Quality Council of India-

Documentation within the healthcare system is like breathing at the end of the day. Documentation only prevents most of the healthcare providers from any legal actions. It also forms a medical legal document within the organization. It is demanded by the court and at the same time even insurance demands it. Similarly if you have completed the document, it also helps the patient for continuity of care. If the documents are maintained well, if the focus is on maintaining and completing the notes, the nursing notes, the prescription audits or the completeness of the medical file, then that helps in continuity of care being provided to the patient from the healthcare provider at any point in time and wherever he wants to go to. So if the discharge summaries are well-maintained or written well, then the patient from North to the South wants to travel and the other doctors tends to see the discharge summary, he should be able to understand what was the treatment given how it was given, what was the response to the treatment and in what condition the patient was discharged.

 

 

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