6th World Nursing and Nursing Care Congress

Biography:

Lorrie Blitch has an impressive and diverse career in nursing and as a business owner. She is owner of Magellan Christian Academies for the past 18 years in Phoenix, Arizona and Jacksonville, Florida. Her schools have won numerous awards including Declaration of Magellan Day by the Mayor of Jacksonville, Florida in 2010. Ms. Blitch was awarded the prestigious title of Top Women in Business in Jacksonville, Florida by Jacksonville Magazine and recognized in Arbus Magazine as a Female Entrepreneur." She is a published author of children's books achieving number one on Amazon. Her experience in nursing is impressive that encompasses critical care, trauma, cardiovascular intensive care, toxicology, administration and management, nursing professor, medical-legal nursing and field hospital nursing. She is a nurse educator for the Banner Health System in Phoenix, Arizona responsible for the education of multiple service lines. Ms. Blitch frequently lectures internationally on nursing topics. She served her country honorably as a Naval Officer for 20 years. Ms. Blitch holds a bachelor's degree in nursing and a master's degree in nursing education and is pursuing a doctorate degree in nurse anesthesia. She sits on the Board of Directors for the Banyon School, New Delhi, India. She lectures on the dangers of academia's "Indoctrination Establishments and the importance of returning to traditional academic learning. 

 

Abstract:

The proper management of documentation in the hospital setting is a paramount duty of healthcare providers, as it greatly affects patient outcome. Nurses, who are in direct care of patient documentation, play a pivotal role in the proper assessment and recording of health data. However, it has come to the attention of healthcare authorities that patient records often have many gaps or deficiencies in information. Many medical records contain inaccurate information, are poorly detailed, or have missing information. This is especially common in patients diagnosed with cancer and elderly patients. For this reason, it is being stressed by researchers that nurses need to strengthen their documentation skills. There are a variety of ways in which to improve nursing assessments, such as training, workplace culture, and proper preparation, which will ultimately result in the improvement of patient well-being. 

Nursing assessments are an important part of proper diagnoses. The creation of progress notes help nurses evaluate patient intervention strategies (Myklebust, Bjørkly, & Råheim, 2018). The relationship between nurses and patients are an important part of patient care, where the nursing process of correct documentation is an influential part of health services. Documentation that is high quality allows for more consistent and structured communication between healthcare providers and patients, and help support their safety (Instefjord, Aasekjær, Espehaug, & Graverholt, 2014). Lack of consistency in this care, such as inaccurate data and misdiagnosis, can result in a longer hospital stay, poor patient satisfaction, hazardous events, re-admissions, and also delays in treatment (Instefjord et al., 2014). Worst of all, the wrong treatment could be provided for a patient which could threaten their life.

 

Nurses who utilized documented information expressed dissatisfaction with other’s form of record keeping. They believed that it is important to record information to provide patients with a form of protection, and that the system of documentation contains too many duplicates, inaccuracies, and missing data (Charalambous & Goldberg, 2016). The main specialties which seem to have reflected many of these errors are in nursing homes, post-operative care, pain management, wound care and orthopedic care (Instefjord et al., 2014). The fields that seemed to suffer most were the geriatric and cancer disciplines. 

Geriatric patient medical records often have the most incomplete, inaccurate, or repetitive data. These elderly patients tend to have complex healthcare requirements, which demands more in-depth geriatric assessments (Charalambous & Goldberg, 2016). This documentation is necessary for decision-making and treatment plans between a multi-disciplinary team to tackle the wide range of health problems that plague an elderly individual. However, nurses felt that the quality of documentation for this population is poor. 

The documentation for patients with terminal cancer also suffers from the same inconsistencies. In a study on patients that had received palliative chemotherapy for advanced pancreatic or lung cancer, it was found that only 4% of these patients had a documented care plan concerning the event of an acute deterioration (Harle, Karim, Raskin, Hopman, & Booth, 2017). These patients in particular had a life expectancy of less than one year. Quality improvement for nursing assessment is crucial for these patients, whether or not they have advanced cancer. It reveals a lack of concern of these patients’ well-being. Similar studies revealed issues in other cancer studies, such as only 6.2% of patients having documentation of cardiopulmonary resuscitation concerning long-term advanced healthcare. 

Methods of improvement include changes in attitude and the record keeping system. The improvement of workflow helped motivate nurses in their data collection initiatives, where one study revealed a 70% increase in documentation of patient data (Harle et al., 2017). Another study revealed that an important connection existed between intention and nursing documentation behavior (Dewi, 2018). These correlations also existed between intention and attitude, as well as intention and perceived behavioral control. The creation of a system of cycles of review, an expert panel of reviewers, and reflection on inputted information can help improve nursing documentation (Stewart, Doody, Bailey, & Moran, 2017). Accessible practice guidelines for enhanced documentation processes can help create better information systems. 

Conclusion

Documentation of patient data often contains inconsistencies such as inaccurate or missing information. The most effected fields that reveal these issues are geriatric patients and advanced cancer patients. As a result, these patients suffered the most neglect. Ways to overcome this issue are to perform audits of nursing documents, as well as implement new attitudes and workflow systems which can help motivate nurses to allow the reformed intention of creating better assessments.