Nursing Documentation System

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In 400 words

Discussion Topic:

Assume you are working with an implementation team in installing a new nursing documentation system for a home health agency. Historically, all of the agency’s nursing documentation was recorded in paper form. The agency has little computerization beyond basic registration information and has no IT staff.

Members of the implementation have made recommendations for installing a new nursing documentation system. Included in the list of recommendations are:

  • The system needs to take into account the State Nursing Practice Act.
    • The system has to include reflect state laws governing the scope of nursing practice.
  • Nurses should be involved in the workflow setup for all medication tasks, including:
    • drug interactions
    • medication failures
    • allergies
  • There should be visit notes template that both nurses and doctors have to approve.
    • Will there be specific notes that only the nurses will approve?
  • Nurses would like to determine how telephone calls are entered into the system.

Create a post, explaining fully, your answer to the questions below.

  • Based on the information learned in the unit readings, would you include the nurse’s recommendations or do you have recommendations of your own? Justify your decision with supportive material.

 

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Intensive Care Unit – Nursing Writers Hub

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this the subject the topic should be on. and a permalimk to the article should be attached to it.
 
The significant clinical issue I have chosen to further research is Intensive Care Unit (ICU) delirium.  Working in an ICU, I have witnessed ICU delirium first hand.  It is quite common in the Trauma ICU in my hospital, because it has no windows. ICU delirium is a significant issue, because it has been linked to negative patient outcomes such as longer hospital stays and higher risk of mortality.  It is a serious issue, because it can be hard to assess until it has already become full blown.  There are suggested tools and preventive measures, but no solid treatment.
Every patient in the ICU is at risk for developing ICU delirium.  On my floor I would say at least 25% of the patients have ICU delirium.  Standard practice at my hospital is to use the CAM-ICU scale once per shift to assess for delirium.  It is common to look through a patient’s chart and see “unable to assess” in the comments.  This is related to the patient being intubated, sedated, and/or the nurse not knowing the patient’s baseline.  Another gap in knowledge is in relation to the fact that there are subtypes of ICU delirium. According to Jun Gwon (2013) “Physicians and other caregivers in the ICU usually notice agitation as a consequence whereas patient with hypoactive delirium, which is a more frequent subtype . . . remain unnoticed” (p. 195).  Noticing that a patient has become aggressive and irritated comes easily, but noticing a patient is not as talkative or less engaged can easily get missed.
Chamberlain School of Nursing (2015). Reading research literature – The research process – Lesson. [Online lecture, Week 2].  Retrieved from nursingonline.chamberlain.edu
Houser, J. (2015). Nursing research: Reading, using, and creating evidence (3rd ed.). Sudbury, MA: Jones & Bartlett.
Jun Gwon, C. (2013). Delirium in the intensive care unit. Korean Journal of Anesthesiology, 65(3), 195-202. doi: 10.4097/kjae/2013.65.3.195
 
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70 Cla2

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Write a paper that includes the following topics: The changing business environment and the pressures for change. Resistance to change and how to overcome it. Business creativity and the needed support to construct the vision and the direction of change. Building a strategic managing innovation model. Blockages to creativity and how to overcome them.

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Justification-Report-Part-3-Final- Custom Nursing Help

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In Assignments 2.1 (Part 1) and 2.2 (Part 2) of the Justification Report, you built up the major parts of your formal, researched justification report (Problem Statement, Overview of Alternatives, Criteria, Methods, Evaluation of Alternatives, Findings and Analysis, and References). For Part 3 you will begin by inserting your revisions of Parts 1 and 2 based on your instructor’s suggestions. Then, you will include a few new sections. Note: Some sections presented below are out of order so pay attention to where the section should go (for instance, the Transmittal should be the second page of your report based on the provided template). It is essential that you present the final report in the correct section order.
Use the basic outline below to draft your paper. Organize your responses to each question under the following section headings:

Preliminary Parts (for Question 1)
Introduction (for Question 2)

Problem Statement (for Question 2b)
Terminology (for Question 2c)
Major Sections of the Report (for Question 2d)
Scope and Limitations of the Research (for Question 2e)

Recommendation (for Question 3)
References (for Question 4)

Using the provided template from Week 4, write Part 3 to complete a single-spaced report in which you:

Create the preliminary parts of the report that precede the Introduction (after reading Chapter 11 in the textbook). Each element (1a to 1d) appears on a separate page (1a should be page 1, 1b should be page 2, etc.). The preliminary part includes:

Title Page
Transmittal (stand-alone business letter)
Table of Contents
Executive Summary

Create an introduction that tells what your report is about. The introduction includes:

Begin with a general introduction paragraph that gives the reader any needed background information on the company or problem.
Include the Problem Statement that you already created and revised in Part 1.
Include terms that readers will need to know in order to understand the report.
Briefly summarize the major sections and findings of the report developed in Parts 1 and 2. Note: This is in addition to including the revised sections not instead of including the revised previous sections from Parts 1 and 2.
Discuss what your report will cover and what it will not (including limitations such as research, time, information, or any other factors the reader should consider when reading the report).

Create the Recommendation section of the Report.

Provide a one to two (1-2) sentence recommendation based on what your Evaluation of Alternatives and Findings and Analysis sections have determined is the most feasible alternative (i.e., solution) to the problem in the Problem Statement.

Create the References section, which goes at the end of the Report by pasting in your revised References page.

Note: Remember to organize the report by the section headings. The report should reflect a style and format appropriate for business; single spacing and bullet points are acceptable for formal business reports.
Your assignment must:

Be typed, single spaced, using Times New Roman font (size 12), with one-inch margins on all sides; citations and references must follow APA or school-specific format. Check with your professor for any additional instructions.
Include a cover page containing the title of the assignment, your name, the professor’s name, the course title, and the date. The cover page and the reference page are not included in the required assignment page length.

The specific course learning outcomes associated with this assignment are:

Support ideas or claims in body paragraphs with clear details, examples, and explanations.
Organize ideas logically by using transitional words, phrases, and sentences.
Use sentence variety and effective word choice in written communication.
Apply writing process strategies to develop formal business reports and / or proposals.
Use technology and information resources to research issues related to selected topics.
Write clearly and concisely using proper writing mechanics.

 
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