RESEARCH TOPIC: “Risk Management - Nursing Documentation”
JOURNAL ARTICLES ANALYIS FOR THE TOPIC
Article 1 – “What is the JCAHO Standard of Documentation for Nurses in Emergency Departments?”
Article 2 – “An analysis of nursing documentation as a reflection of actual nurse work”
Financial Institutions Management
By
Management Major: Nathalie Touko Millimono
Business Information Technology Department
Risk Management - Acute Care Hospital: Nursing Documentation
Introduction
The issue of documentation of patient care has received considerable attention in the past few years for a variety 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. Our facility has indicated that nursing documentation is the area of the greatest risk management.
In this era of unprecedented change in healthcare, our facility has determined it was time to reengineer our existing approach to risk management consulting services to address more current needs for our patients and staff.
New Approach
The primary technique utilized in overcoming these limitations is to view training not as a stand-alone solution, but rather as one component of a full performance improvement plan to address specific areas of concern. Instead of providing a general program on documentation, the consultants have been working with the risk managers and other professionals to focus on the areas of deficiency or situations that need the most improvement. The cornerstone of the consultative process has been to:
* pinpoint the exact nature of the medical record deficiency
* Develop criteria and expectations to improve documentation
* Describe the current deficiencies as...