May 4, 2012
Susan Dean, RN, MSN, FNP
Risk Management Nursing Documentation
The issue of documentation of patient care has received considerable attention in the last few years for an array of reasons. Trends in society such as increased consumer education, informed consent, expectation for healthy baby, and an increasingly litigious society all contribute to increased risk management awareness on behalf of healthcare facilities. Risk management deals with the probability that a given risk will result in poor outcome and then attempts to reduce probability. El Centro Regional Medical Center (ECRMC) has identified nursing documentation as an area of greatest risk …show more content…
Other activities include reinforcement in monthly staff meetings, self-study modules, concurrent review and feedback in the clinical areas and feedback of follow-up audit data to reinforce improvement and remind staff who are not complying to do so.
After the intervention is completed, measurement through data collection occurs. Chart audits should are performed at least quarterly for one year after the intervention, in order to assure the improvement is continued.
The sample selected for chart audit may not be large; however, it should be enough to evaluate various staff members from all departments or units. A well-organized structured workflow makes it easier for nurses to document care completely as well as comply with increasing regulatory demands. Nurses can streamline common tasks like charting vitals, intake/output, and patient education. Interfaces to patient monitoring devices allow for hands-free, paper-free capture of critical measurements. Activity Assignment Engine automatically populates each care team member's work list with relevant items, helping nurses review and coordinate the care their patients need. The intuitive layout helps nurses organize their day and ensure that all tasks are covered even across shifts. Template-driven Discharge Instruction Writer ensures complete, relevant patient instructions without a