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Essay / Research Paper Abstract
A 15 page paper proposing research into the completeness and appropriateness of nurse documentation at a teaching hospital for a period of one month. Nurse documentation formerly was a topic that was discussed only as a matter of instruction and requirement for complete patient records. Though that perspective remains valid in today’s health care environment, the issue of nurse documentation has taken on a far greater role in both practical and administrative terms. Nurse documentation must be appropriate, and for a variety of reasons. Of course the issue of patient safety and completeness of care remains the leading one, but reimbursement by third-party payers increasingly is dependent on appropriate nurse documentation. The need for appropriate nurse documentation is only expected to increase in the future. Bibliography lists 24 sources.
Page Count:
15 pages (~225 words per page)
File: CC6_KSnursRePrMed-Surg.rtf
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Unformatted sample text from the term paper:
formerly was a topic that was discussed only as a matter of instruction and requirement for complete patient records. Though that perspective remains valid in todays health care environment,
the issue of nurse documentation has taken on a far greater role in both practical and administrative terms. Nurse documentation must be appropriate, and for a variety of reasons.
Of course the issue of patient safety and completeness of care remains the leading one, but reimbursement by third-party payers increasingly is dependent on appropriate nurse documentation. The
need for appropriate nurse documentation is only expected to increase in the future. The study will be a qualitative one, using a cross-sectional
correlational design through which we will strive to gain a perspective on nurses attitudes and perceptions of nurse documentation responsibilities and the emerging trend of creating electronic patient charts rather
than traditional paper ones. Theoretical Framework Roys theory of the environment will provide a basis for the study (Leddy and Pepper, 1998).
Neumans system theory will supply a basis for analysis of the organizations medical/surgical nurses, as they constitute a community within the larger community of the hospital in which they work
(Fawcett, 1995). Application of either model rests in large part on the appropriateness and completeness of nurse documentation (Torakis and Smigielski, 2000). Literature Review Financial Considerations
Aside from the requirement for keeping complete patient charts, nurse documentation is not a topic that historically has received a great deal of attention. The
still-evolving nature of todays health care environment, however, brings increasing focus on the need for appropriate and complete nurse documentation. All care-providing organizations are pressured in budgetary areas in
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