Case studies poor nursing documentation
A case study is a story about something unique, special, or interesting—stories can be about individuals, organizations, processes, programs, neighborhoods, institutions, and even events 1 the case study gives the story behind the result by capturing what happened. Case study assessments 18 case study: inpatient palliative care service the patient’s journey mr george callis is an 89-year-old man who was diagnosed with metastatic lung cancer george her appetite is poor but her intake is reasonable 3 small meals every day with snacks ann prepares her meals. Case study 3 issue: patient identification and demographic data: automated patient registration data elements/patient safety risks failure of an ehr system to provide appropriate safeguards against medication errors, including the wrong patient, the wrong drug, or failure to consider all available data, can contribute to poor quality care. Nursing care plan lpn - nursing nursing notes nursing pins nursing documentation nursing research care plans respiratory therapy nursing students forward 20 million people in the united stated have asthma, a chronic respiratory disease that makes it impossible for them to take breathing for granted. This is the case study used during the “your medical documentation matters” presentation it is your medical documentation matters 3 case study jk is a 52-year-old male patient he is 6 feet tall and weighs 265 pounds and that jk had not received any wound care prior to admission.
Expert witnesses are used by both prosecuting and defense attorneys to establish standards of care depending on the kind of legal case, an expert witness could be a nurse, a doctor or a facility facilities caring for the elderly and/or the poor page 5 the best defense is a good documentation offense ii what b. Review the case scenario and accompanying table documenting evidence-based practice from chapter 14 and then utilize the blank table for your own research purposes case study #1 completed ebp form for case study #1. This case study describes the experience of a stand-alone community hospital as it struggled it is hospital policy for the nurses to document each patient’s care into the nursing documentation system during a shift, including a shift end summary the. Improving transitions of care: hospital to home rev10/29/09 1 improving transitions of care: not only can poor transitions lead to poor care quality, transitions of care issues pose a financial burden for the health insurers, the government, and risk for poor outcomes case study: in a hospital/home transfer, consider 4 exchanges.
Nursing care for a patient scenario 2 case study – nursing care for a patient scenario (mrs jones. A malpractice case ensued in which the patient claimed he’d been neglected all day long and the nursing student’s charting was deliberate fraud take-away point: never leave a blank space when paper-charting, and never insert your documentation into a blank space left by another nurse. Documentation: a case study of the impact on health services funding ping cheng, annette gilchrist, kerin m robinson and lindsay paul dramatically by using nursing case managers’ patient progress summaries’ (curtis, bollard & dickson 2002) the facility for poor care in this instance, patient.
Poor documentation defined before tackling a documentation problem, health care organizations must elucidate whether indeed there is a problem in the first place determining the specifics of what constitutes poor documentation is the first step. Study after study has shown that poor communication leads to a shocking number of avoidable hospital injuries and deaths in fact, the organization that accredits hospitals, the joint commission on the accreditation of healthcare organizations (jcaho) realized that communication was a major problem that required nationwide correction. Start studying hesi case studies--pediatrics-cystic fibrosis (debbie baker) learn vocabulary, terms, and more with flashcards, games, and other study tools.
Case studies poor nursing documentation
Although documentation within the ehr can improve coordination of care, improve patient outcomes, improve quality of care, and enhance provider insight-- it does not provide insight into patient preferences and values, which is the main component of patient-centered care. Case study: nursing documentation in the electronic age october 15, 2017 concerns with the delay in nursing documentation providing care to others in their most desperate and vulnerable state is an honor for those providing the care. • reduce risk in documentation • validation through documentation • comparison of paper documentation versus electronic documentation • how to use the nursing process in documentation • use of actual case studies to clarify appropriate documentation.
- Case study the university of tennessee medical center reduces documentation costs by 70% comprehensive and intuitive clinical documentation, satisfied physicians the university of tennessee medical center in knoxville is doing the hard work required to improve care coordination and transition into the world of value-based care.
- The coroner highlighted in this case that poor communication both verbal and documented contributed to the death of mr gilliam the ability to communicate well is an essential skill for medical and nursing staff (moore, 2005.
Of nurse documentation on a stoma care ward in a large london hospital, and explores the factors that may affect the process of record keeping by nursing staff this study uses stoma care as a case study to explore the role of documentation. Appropriate legible documentation provides an accurate reflection of nursing assessments, changes in conditions, care provided and pertinent patient information to support the multidisciplinary team to deliver great care. The falls management program: a quality improvement initiative for nursing facilities appendix c case study and program examples previous page next page table of contents the falls management program: a quality improvement initiative for nursing facilities chapter 1 introduction and program overview.