Improve Patient Safety

McKessons nursing documentation solutions improve patient safety by helping to reduce medication errors, to identify at-risk patients, and to facilitate timely and shared information.

Improve Clinical Performance

While regulatory compliance and quality improvement initiatives mean constantly raising the bar, it shouldnt be such a burden for the clinical staff. McKessons solutions allow nurse leaders to manage quality and clinical outcomes with tools that allow organizations to cost-effectively implement rapid and sustainable clinical quality improvements and improve quality of care using continuous feedback. Todays healthcare executives must navigate a sea of health care quality measures and regulatory requirements that create a considerable burden on hospital staff and budgets. Accurately and efficiently collecting data for reporting purposes is difficult enough, but the real challenge is using the data to improve health care quality and patient safety while reducing health care coststhe ultimate goal of every indicator and evidence-based standard. McKessons clinical improvement solutions help healthcare organizations achieve health care quality performance improvements they can assess, measure and sustain. Our full spectrum of management reporting capabilities, caregiver compliance tools and advanced clinical analytics simplify data collection and reporting while facilitating sustainable care process changes. The result is streamlined compliance, reduced health care costs and a unique edge in turning evidence-based standards into measurably better patient outcomes. With a focus on turning data into knowledge, McKessons clinical improvement solutions combine with your existing clinical systems to help you measure and improve their effectiveness in meeting your patient safety and quality improvement goals.

Articles
Nursing documentation must make sense, must have meaning, and must communicate.
Effect of Poor Documentation
Has poor documentation impacted patient care in your facility? Has the use of bad abbreviations wasted time and detracted from patient care? (See the articleAbbreviations: A Shortcut to Disaster on this page for more on the topic.) Has your organizations' bottom line been affected because equipment, medication, or treatments were not properly documented? If you completed a patient assessment and then looked at a previous assessment, could you make a better decision about what to do next for the patient? If the previous assessment was properly documented, the answer would be yes. But if the previous documentation was incomplete, then the employee would have a hard time making a good decision! Documentation does impact the quality of care given. Maybe the reason for the complaint that "no one reads our charts" is because nurses do not say what needs to be said! Documentation must be accurate, clear, concise, complete, and timely. Speed is of the essence when working in healthcare, but accuracy and completeness are imperative when documenting. Do not let the patients health be compromised by worrying about the speed; make sure it gets done right the first time. Documentation must have meaning today, tomorrow, and in the unforeseen future. One of the difficulties with documentation is that we never know when what we document will be needed. You want to make sure the right information gets documented and that documentation is done correctly. Nursing documentation is important and not just for legal purposes. The results and benefits of nursing documentation are greater than the sum of the tasks themselves. It isnt an easy task, but it is necessary and it is a way of giving high-quality patient care. The lack of proper documentation can negatively impact patient care and can ultimately cause other problems.

Abbreviations: A Shortcut to Disaster

This article poses some interesting thoughts for your staff and the use of abbreviations in their documentation. Are they hurting the patient, themselves, and your organization?

Are you putting your patient at risk by

using abbreviations? Are you putting your career at risk by using abbreviations? Nurses are supposed to be communicators, especially when documenting patient information. If what we write does not communicate, then we have failed in our professional and legal responsibilities. Furthermore, we have failed our patient and our employer, thereby putting all at risk. When documenting, it is imperative that we do not put our patients lives at risk because of the methods we use for the task. These methods include the use of abbreviations. The indiscriminate use of abbreviations can be extremely dangerous to the patient and the nurse and a major waste of time. 1. Abbreviations can be a total mystery to the reader. If a doctor wrote "Patient may get up AFAWG," would he have communicated with you? How much time would you have to spend trying to figure out what

This was shown with nursing research done by Paice, et al., who found that pain management of surgical oncology patients was inadequate. They stated that the lack of documentation they found in their study led to a "...lack of consistent care and the inability to evaluate the effectiveness of pain therapies."1 Their research becomes even more important in light of new consideration of pain as the fifth vital sign and JCAHOs emphasis on pain management this year. Continued

he meant? If you and two other nurses looked at this order for 90 seconds each, four and a half minutes of patient care time would have been wasted. Plus you probably still would not have the correct answer. 2. Abbreviations are easily confused. Patients are still being overdosed with insulin and heparin because people use "u" for units. Another critical error can occur with the use of "g" for "microgram," which has been misinterpreted to mean "mg" for "milligrams." Any of these situations could lead to a serious medication error and catastrophic results for the patient. How would you like to write the incident report on the newborn who received ten units of insulin instead of the one unit he was suppose to receive? This type of error automatically multiplies the dosage by a factor of ten. 3. Next, abbreviations that start out as time-savers can end up as time-wasters. As nurses, we often use abbreviations to speed documentation. But does the reader get our intended message? Ask three nurses what "pt voided qs" means. One might tell you "voiding quantity sufficient" and another one might say "voiding every shift." Try this abbreviation: "MSO4." Did you say morphine or magnesium? I have received both answers in every class where I asked the question. The differences in these

interpretations could have devastating consequences.

REASONS FOR DOCUMENTATION To facilitate communication Through documentation, nurses communicate to other nurses and care providers their assessments about the status of clients, nursing interventions that are carried out and the results of these interventions. Documentation of this information increases the likelihood that the client will receive consistent and informed care or service. Thorough, accurate documentation decreases the potential for miscommunication and errors. While documentation is most often done by nurses and care providers, there are situations where the client and family may document observations or care provided in order to communicate this information with members of the health care team. To promote good nursing care Documentation encourages nurses to assess client progress and determine which interventions are effective and which are ineffective, and identify and document changes to the plan of care as needed. Documentation can be a valuable source of data for making decisions about funding and resource management as well as facilitating nursing research, all of which have the potential to improve the quality of nursing practice and client care. Individual nurses can use outcome information or information from a critical incident to reflect on their practice and make needed changes based on evidence.

To meet professional and legal standards Documentation is a valuable method for demonstrating that, within the nurse-client relationship, the nurse has applied nursing knowledge, skills and judgment according to professional standards. The nurses documentation may be used as evidence in legal proceedings such as lawsuits, coroners inquests, and disciplinary hearings through professional regulatory bodies. In a court of law, the clients health record serves as the legal record of the care or service provided. Nursing care and the documentation of that care will be measured according to the standard of a reasonable and prudent nurse with similar education and experience in a similar situation.

Abstract
This study aimed to explore complexities in nursing documentation and related factors. Nursing documentation has been one of the most important functions of nurses since the time of Florence Nightingale because it serves multiple and diverse purposes. Current health-care systems require that documentation ensures continuity of care, furnishes legal evidence of the process of care and supports evaluation of quality of patient care. However, nursing documentation has not served such objectives because of its complexities. This study explores nursing documentation complexities and related factors through both qualitative and quantitative methodologies. The study used multiple methods of inquiry: indepth interviewing; participant observation; nominal group processing; focus group meetings; time and motion study of nursing activities; and auditing of completeness of nursing documentation. Complexities in nursing documentation include three aspects: disruption, incompleteness and inappropriate charting. Related factors that influenced documentation comprised: limited nurses' competence, motivation and confidence; ineffective nursing procedures; and inadequate nursing audit, supervision and staff development. These findings suggest that complexities in nursing documentation require extensive resolution and implicitly dictate strategies for nurse managers and nurses to take part in solving these complicated obstacles.