Standard Documentation in Nursing

Standard Documentation in Nursing

Introduction

Standard documentation involves keeping and managing information of an individual organization using electronic means. This keeps the information secure and prevents loss. It also denies access to information by unauthorized personnel (Owen, 2011). The system also provides reliable information for easy retrieval. Standard documentation provides evidence of an individual event when clarity is needed. It ensures Consistency which is vitally essential for smooth running of an organization. Standard documentation is also important when dealing with company issues such as hearings, disciplinary activities, redundancy decisions and promotion.

Standard documentation plays a very crucial role in nursing. First, the system ensures increased visibility of nursing interventions. Nurses need to disclose transparency in what they do for patients. Nursing interventions are kept invisible from the other people. Due to this, nursing languages have been created to ensure transparency and openness in their work.  Responses are taken to support nursing judgments using nursing languages. For example, NIC language is used to evaluate the cervical status and verifying presentation (Moody, 2010). Standard documentation ensures improved patient care.  NIC management provides good well being of patients while interacting with the nurses and health partners. NIC program provides transparency and openness since it exposes every single activity that happens between the patient and nurses. The system ensures that patients are not mistreated, and correct medication is administered (Owen, 2011).  It provides enhanced data collection to evaluate nursing care outcomes.  For example, NOC system is very sensitive to interventions performed primarily by nurses. The system discloses everything about nurses.

This is because all nursing activities are made visible and therefore can be evaluated. Standard documentation ensures standards of care adhere. Nurses ensure that their daily activities are kept standard and fully comply with standards of good health care. The system facilitates assessment of nursing competency (Moody, 2010). Nursing interventions delineated in standard nursing programming languages can be considered as measures to evaluate nurse competency in the performance of these interventions. Such languages include the NIC system, CCC, NANDA, and   NOC system (Owen, 2011). The system ensures that laws regarding medical activities are implemented.

Network on chip (NIC) is a flexible and scalable communication tool. Network on chip system is very reliable and convenient since it provides the exact information about the intervention.  However, it is very expensive to install and put into practice. The system can also be interfered with and cracked down. In conclusion, standard documentation is of great use in our lives. It provides information and concrete evidence on every activity that transacts in any organization. It is also an electronic system which is very convenient to implement.

References

Moody, L. E., Slocumb, E., Berg, B., & Jackson, D. (2010). Electronic health records documentation in nursing: nurses’ perceptions, attitudes, and preferences. Computers Informatics Nursing, 22(6), 337-344.

Owen, K. (2011).Documentation in nursing practice. Nursing standard, 19(32), 48.