State-of-the art
Foreign Author
done after rendering care to the patient. It should be updated minute by minute
gaps can be a potential problem during litigation that is why accuracy is after
being practiced.
Effective Documentation reflects the quality care and provides evidence of each
health care team member’s accountability in giving care. The record serves as a
description of exactly what happened to a client. Nursing care may have been
excellent however; “care not done is care not done” in a court of law.
Navuluri (2007) emphasized that complete documentation will be very
beneficial to the patient especially in improving the quality care provided. Caring
for patient; dealing with special situation; and practicing self legally; each entry
tells exactly what to consider and document, so the nurses can ensure quality
patient care, continuity of care, and legal protection like provides practical advice
document safely and correctly to ensure quality and continuity of care. Also uses
case histories to illustrate key legal –points and to explain how and why to
nursing activities to ensue the highest quality of care. Allows the nurse to
determine which problems can be alleviated and which potential problems can be
health care team. Meaning, nurses and other health care provider has
assessment.
Local Author
in giving such care. It should be accurate and concise with the patient’s needs,
must be complete and concise , speed is essential but making it slowly and
As cited by Raymond (2002), The nursing files, no matter how they are
created and reserved, they have the ability to be modified due to new data, and
documentation means all the common condition encountered in long term care at
determine the quality of care that the nurse had provided to the patient, it is used
Foreign Thesis
continuity of care. It acts as legal evidence during the nursing process and it
enhances the quality of patient care. Though it has complexities the nurse must
possible. Documentation has always its complexities but it only requires a good,
undeniable for the reason that it organizes his care, and facilitates the
communication among the members of the therapy group. The nursing files, no
matter how they are created and reserved, they have the ability to be modified
dew to new data, and that renders nursing documentation a dynamic process.
registered nurses but isn’t sufficient, it must be used in combination with other
complex methods.
Lamond L,(2002) held that The report of the shift change is the report that
is given to all the nurses of the next shift. Its purpose is to provide constant care
to the patients, giving to the employees of the new shift a brief summary of the
needs of the patients and instructions for their care. The reports during the shift
the nurses or by a recording cassette. The report person by person allows the
listener to make questions during the report. The written and recorded reports
This process influences the perceptions of long term care (LTC) administrators,
which then influences their actions. The question does the advanced education
the results indicated that there are no significant difference in the mean scores
between those administrators with higher degrees and those with less than
degree. Knowledge of trend in health care and quality assurance was second
and the third most important competencies indicated needed by both groups. No
Local Thesis
(2008), Stated that documentation is concerned with the status of the patient.The
Documentation also promoted better care from the nurse to the patient.It
supports the rights of the patient and meets the legal standards of the nurse.
enough to retrieve clinical data, maintain continuity of care and reflects current
fundamental communication with the other health care teams and it serves as the
patients perspective on his/her health and well being, the care provided and the
recording of the interventions that concern the patient and it includes a sequence
patient, which constitutes a base of information on the situation of his health. The
care for the patient. In the purposes of nursing documentation are included the
programming of care. The patient’s file should describe his current situation and
reflect the entire nursing process. Regardless of the documentation system that
seniors, finding out that there is a significant between hindrances and their
gender.
Foreign author
Local author
Venzon & Nolledo. Nursing management towards quality care. C& E publishing
Inc. 2006
Foreign thesis
Boldreghini S, Elder – Sorrells K,Turner ZM, Wender RG, Hart JM, et al.
Evaluation of documentation, before and after implementation of a nursing
information system in an acute care hospital. 2000
Local thesis
Catalano K, Critical path network: Improve patient safety to comply with new
standards: Demonstrate evidence to JCHAO surveyors. Hospital Case
Management. 2001