Boards of Nursing (BONs) exist in all 50 states, the District of Columbia, American Samoa, Guam, the Northern Mariana Islands, and the Virgin Islands. 

Please answer the questions below on regards of   

Inadequate Pain Management in Postoperative Patients

1. Regarding your presentation assignment, what did you learn about the research project?
2. Would you have approached the assignment differently? Why or why not?

Submission Instructions:

• Post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. 

Respond to Kaffy

Ensuring accurate and confidential documentation in nursing is crucial for patient care, legal compliance, and maintaining the integrity of healthcare records. However, nurses face several challenges in achieving this goal. Three prominent challenges include workload, knowledge, and complex documentation systems.

Firstly, nurses often contend with heavy workloads that can make it challenging to dedicate sufficient time to accurate and complete documentation. The demands of patient care, frequent interruptions, and the need to juggle multiple tasks can sometimes hinder their ability to maintain comprehensive records (Cimino, 2013).

Secondly, nurses need to possess a deep understanding of documentation policies, procedures, and the legal implications of inaccuracies or omissions in their records. Knowledge gaps in these areas can result in documentation errors that compromise patient care and expose healthcare facilities to legal risks (Cimino, 2013).

Thirdly, the documentation systems that nurses use can be complex and not always user-friendly. Navigating these systems effectively requires training and familiarity, and any difficulties in system operation can affect the accuracy and confidentiality of documentation (Cimino, 2013).

To overcome these challenges, nurses can take proactive steps:

Workload Management: Nurses can prioritize their documentation tasks and seek opportunities to delegate tasks when possible. Utilizing informatics tools can help automate certain documentation processes, alleviating some of the time constraints (American Nurses Association, 2020).

Knowledge Enhancement: Nurses should seek out training programs related to documentation policies, procedures, and legal implications. They can also collaborate with colleagues or healthcare professionals for guidance and clarification on documentation-related queries.

System Proficiency: To tackle the complexities of documentation systems, nurses should invest time in learning how to use them effectively. They can also report any system-related issues to their supervisors, advocating for improvements where necessary (American Nurses Association, 2020).

The integration of informatics into nursing practice can play a transformative role in addressing these challenges. Informatics tools can:

Automate Documentation: By automating routine documentation tasks like generating nursing notes or medication administration records, informatics can significantly reduce the time burden on nurses, allowing them to allocate more focus to patient care.

Provide Alerts and Reminders: Informatics systems can offer real-time alerts and reminders, ensuring that nurses complete documentation tasks in a timely and accurate manner. These cues can be invaluable in preventing oversights (American Nurses Association, 2020).

In summary, informatics offers a multifaceted solution to the challenges nurses face in documentation. By automating tasks, providing reminders, improving data access, and enhancing security, it empowers nurses to deliver more accurate, complete, and confidential documentation while mitigating the obstacles presented by workload, knowledge, and complex systems.

References

Nursing Documentation and Informatics: A Core Competency for Nurses. (2020). American Nurses Association

Cimino, J. J. (2013). Nursing Documentation: Informatics for the 21st Century. (4th ed.).

Respond to Muni

1.Data Accuracy and Completeness: 

Maintaining the accuracy and completeness of patient information is one of the biggest issues in nursing documentation. The many duties that nurses must complete may cause them to forget to record important patient information or cause mistakes. Keeping the record updated in real-time may also be difficult if the patient's health changes quickly.

Strong observational and documenting abilities would be needed to overcome this difficulty. Peer evaluations, training workshops, and regular audits of medical records can all be beneficial. Electronic health record (EHR) solutions offered by informatics can significantly contribute to the reduction of errors by automatically recording and updating some patient data (such as vital signs from connected monitors).

2.Confidentiality and Privacy: 

Maintaining patient data security In nursing practice, confidentiality is essential. However, problems might occur as a result of unauthorized access, data breaches, or even an inadvertent disclosure of private information during normal conversations.

Nurses can avoid this by properly following HIPAA rules and upholding their professional limits. Staff members should receive comprehensive cybersecurity training and should only access patient data when necessary. Data security can be strengthened with the use of informatics systems like EHRs, which can assist with access controls, encryption, and audit trails to trace who is accessing data.

3.Time Constraints: 

Due to their busy schedules and time constraints, nurses may struggle to accurately and swiftly record patient information. As a result, there can be a delay in recording or inaccurate data.

This challenge can be lessened with good time management techniques and delegating when appropriate. Informatics is involved once again in this situation. Technologies like speech-to-text software and electronic health records (EHRs) help speed up the documentation process and note-taking. Nurses can document data at the point of care more quickly with the use of mobile devices.

Keep in mind to comment on other entries and offer helpful criticism. To improve our collective nursing practice, we may all benefit from exchanging real-world experiences and solutions.

REFERENCE

· https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6111626/

· https://bmcresnotes.biomedcentral.com/articles/10.1186/s13104-019-4661-x

· https://www.nuance.com/asset/en_uk/collateral/healthcare/ebook/eb-nuance-nurse-clindoc-screen.pdf

· https://www.frontiersin.org/articles/10.3389/fcomp.2021.624555/full

please follow all directions

Cassandra Birth

Yesterday Oct 2 at 11:04am

Bar code medication administration (BCMA)

Bar code medication administration (BCMA) is when the patient’s armband is scanned along with the medication, if they match, the medication may be administered (Hebda et al., 2019). This is new technology that helps prevent medication errors. BCMA and e-MAR ensures that the right patient receives the correct medication, this adheres to the 5 patient rights for medication administration (Naidu & Alicia, 2019, p. 511). The 5 patient rights for medication administration are right patient, right medication, right time, right dosage, and right route. While scanning the patient and each medication, if the e-MAR doesn’t recognize the medication for the patient, it won’t allow for the nurse to document that it was given. However, nurses still need to be aware of these pop-ups and place the medication aside because that medication isn’t supposed to go to that patient at that specific time and they need to figure out why. BCMA doesn’t completely prevent medication errors. Nurses still need to focus on the medications they are giving to their patients. Getting distracted by patients and their families can cause the nurse to misplace a medication when scanning them. Ensuring that all the scanned medications are the ones actually given to the patient is critical. Nurses still need to be aware that some medications may be the wrong dosage and may need to be split. They also need to be aware of vital signs and if the medication is still appropriate for the patient to take. Ethically this can be taking away some of the nurse’s autonomy of checking the medication name, dosage, and expiration date on the medication label. BCMA is supposed to reduce medication error, but nurses still need to be focused when administering medications. They need to ensure the patient is in the right condition to be taking specific medications. BCMA doesn’t take into consideration patients vital signs and stability to take a medication, so the nurse will have to still document “not given” in these scenarios. Patient armbands could also be ripped, or wet and unreadable to the scanner. Ensuring that the scanner is working properly and if something is wrong to fully check that it is the correct patient before administering the medications.

Naidu, M., & Alicia, Y. L. (2019). Impact of bar-code medication administration and electronic medication administration record system in clinical practice for an effective medication administration process. 
Health, 
11(05), 511-526. 

https://doi.org/10.4236/health.2019.115044

Links to an external site.

Hebda, T., Hunter, K., & Czar, P. (2019). 
Handbook of informatics for nurses & healthcare professionals (6th ed.). Pearson.