Risk Management Nursing Documentation Nur 492

In: Science

Submitted By bedaz13
Words 1020
Pages 5
Risk Management Nursing Documentation
Oscar Chavez
NUR 492
May 4, 2012
Susan Dean, RN, MSN, FNP

Risk Management Nursing Documentation

The issue of documentation of patient care has received considerable attention in the last few years for an array of reasons. Trends in society such as increased consumer education, informed consent, expectation for healthy baby, and an increasingly litigious society all contribute to increased risk management awareness on behalf of healthcare facilities. Risk management deals with the probability that a given risk will result in poor outcome and then attempts to reduce probability. El Centro Regional Medical Center (ECRMC) has identified nursing documentation as an area of greatest risk management. In this era of unprecedented change in healthcare, ECRMC has determined it was time to reengineer our existing approach to risk management consulting services to address more current needs for our patients and staff.
The primary technique utilized in overcoming these limitations is to view training not as a stand-alone solution, rather as one element of a full performance improvement plan to address specific areas of concern. Instead of providing a general program on documentation, risk management has been working with nursing departments and other professionals to focus on the areas of deficiency or situations that need improvement. The foundation of risk management was broken into four separate issues. One was to pinpoint the exact nature of the medical record deficiency. Second was to develop criteria and expectations to improve documentation. Third, the current deficiencies were described as well as expectations for improvement via training and other sources to staff. Finally, a method was developed for measuring progress.
Risk management has taken the following pattern. Risk management nurse meets with the floor…...

Similar Documents

Risk Management Nursing Documentation Nur 492

...Risk Management Nursing Documentation Oscar Chavez NUR 492 May 4, 2012 Susan Dean, RN, MSN, FNP Risk Management Nursing Documentation The issue of documentation of patient care has received considerable attention in the last few years for an array of reasons. Trends in society such as increased consumer education, informed consent, expectation for healthy baby, and an increasingly litigious society all contribute to increased risk management awareness on behalf of healthcare facilities. Risk management deals with the probability that a given risk will result in poor outcome and then attempts to reduce probability. El Centro Regional Medical Center (ECRMC) has identified nursing documentation as an area of greatest risk management. In this era of unprecedented change in healthcare, ECRMC has determined it was time to reengineer our existing approach to risk management consulting services to address more current needs for our patients and staff. The primary technique utilized in overcoming these limitations is to view training not as a stand-alone solution, rather as one element of a full performance improvement plan to address specific areas of concern. Instead of providing a general program on documentation, risk management has been working with nursing departments and other professionals to focus on the areas of deficiency or situations that need improvement. The foundation of risk management was broken into four separate issues. One was to pinpoint the exact...

Words: 1020 - Pages: 5

Interview with Health Care Leader Nur 492

...Interview with Health Care Leader NUR 492 October 8, 2012 Interview with Health Care Leader Leaders are someone that can be a positive influence in anyone’s life. Leaders are someone that people look up to and remember that person throughout his or her lives. The leader exerts influence by using a flexible repertoire of personal behaviors and strategies (Sullivan, Decker, 2009). The leader I chose to interview was the Infection Prevention Coordinator of the hospital. A leader needs to have personal skills, be knowledgeable, be able to adapt to his or her environment, and lead by example. The hospital Infection Prevention Coordinator in the hospital I work at has the qualities of a leader. The hospital Infection Prevention Coordinator has been employed at our hospital for eighteen years. She has held different positions while employed at the hospital. She stated that she first worked as a nurse manager in the med surge unit and ten years ago became the Infection Prevention Coordinator. She states that she has been in nursing for over thirty-five years; she got her BSN and then worked for her Master’s in Health Education. She stated that she wanted the position of Infection Prevention Coordinator to help the community as well as the hospital from communicable disease. When asked the question “How would you describe a leader?” the IPC answered, “A leader is someone that is not selfish and incorporates listening skills, communication, and being available to staff...

Words: 1495 - Pages: 6

Documentation

...VISION To achieve quality, reliable service and make IETI a center of excellence through innovative technology-based education. Mission Through strong and responsive management together with the united, committed academic and non-academic personnel, IETI will produce world-class multi-skilled graduates. IETI HISTORY In July 1974, the International Electronics and Technical Institute, Inc. was born. It was formally incorporated and duly registered with the Securities and Exchange Commission. It established its first school on the second floor of the Galvez Building at Taft Avenue Extension in Pasay City and started operations in school year 1974-75 offering one and two- year course in electronics. In 1975, the Institute opened schools in Cubao and Makati. The Makati School, located on the mezzanine floor of the Guadalupe Commercial Complex at first, offered only courses in electronics, later it expanded to include electricity, radio communications, refrigeration, automotive, typing and stenography among its course offerings. IETI Cubao, located on the fifth floor of the Dona Victoriana building at EDSA corner New York St. also began with electronics courses specializing in radio and television. In 1981, further expansion of the Institute included the offering of the two-year Electronic Computer Technician courses in its Pasay and Cubao schools, thereby earning the distinction of being the first private school in the Philippines to offer such a program. In...

Words: 1629 - Pages: 7

Nur/405 Family Nursing Diagnosis

...Family Nursing Diagnosis Susan Kenney, RN NUR/405 June 9, 2014 Beth Edwards, MSN, FNP-BC Family assessment, roles and structure The family I have been working with consists of three sisters who live in a house owned by the eldest of the three, C.H. C.H. is a 64 year old Caucasian female who was born with cerebral palsy and mental retardation. She has never been able to walk, and her mentation never progressed past the age of an approximately 4 year old child. She lived at home with her parents and two sisters and one brother until the age of 11 when she was institutionalized in a facility notorious for the mistreatment and neglect of its residents. The facility has long since closed, and in 1991, C.H. was placed with our organization, Community Vision Inc. (CVI). Her parents were both deceased by that time, and her sister D.H.C. assumed legal guardianship, with sister N.W. helping with her needs. CVI is a non-profit organization that assists disabled individuals to live as independently as possible, and enables them to purchase and live in their own homes if possible. We provide caregivers and in collaboration with social services and interdisciplinary personnel facilitate the supported individual to live to their maximum potential. Each person has their own individual service plan with health, safety, and vocational goals, and staffing is provided as required to meet the individual’s needs. Assessment of C.H. and her living situation The home the...

Words: 3852 - Pages: 16

Documentation

... simplified computerized inventory system will be very helpful to the company since this will expedite its inventory workflow as well as generate very timely reports needed by the management for its evaluation and review and overall decision making. An inventory control system is a process for managing and locating objects or materials. In common usage, the term may also refer to just the software components. Modern inventory control systems often rely upon barcodes tags to provide automatic identification of inventory objects. Inventory Systems help companies with huge inventories to easily and accurately monitor their stocks. With the use of a database, information will be readily available to the user and can be easily updated without having to scroll through spreadsheets. 1.2 Statement of a problem The proponent’s problem is to create an proposed system that will help and responds to the needs of the mercury drug store. 1.2.1 General Problem How to improve the manual point of sales and inventory? -The researcher’s main problem is to create a Computerized point of sale and inventory System that will every time assure every process and transaction is done more accurately and in more secure manner. 1.2.2 Specific Problems The main problems that needs a responds or a solution is that provision of a system that shows how to process the enrollment system. * How to secure the information that is stored in the proposed system? * How to generate accurate...

Words: 944 - Pages: 4

Documentation

...THE PERCEPTION OF FIRST YEAR STUDENTS TAKING UP BACHELOR OF SCIENCE IN HOTEL AND RESTAURANT MANAGEMENT IN TAGUIG CITY UNIVERSITY CHAPTER 1 THE PROBLEM AND ITS BACKGROUND Introduction Hospitality is one of the major service sector when it comes in the business world it is also one of the most interesting and challenging industries to work in and offers a wide range of job and career opportunities and an endless variety of places to work in and it comprised of customer service. Hospitality is the business of helping people to feel welcome and relaxed and to enjoy themselves. You may be providing them accommodation, a meal or a cocktail or even entertaining them. The Bachelor of Hotel and Restaurant Management is geared towards equipping students with the necessary knowledge, skills, and attitude to provide quality service in the hospitality industry. It contains subjects that will address the needs of different sectors in the hospitality industry, such as culinary, front office, tourism, resort and hotel operations. Its primary concentration is on the development of practical and management skills which are achieved through the combination of theoretical classes, practicum exercises and experiential learning. Hotel and restaurant management trains to be more knowledgeable in their chosen career and being part of a hospitality industry is very exciting experience rather than other courses because in this field you can interact to other people by giving them your best...

Words: 502 - Pages: 3

Nur 492 Uop Course Tutorial/Tutorialrank

... structure create an environment of support for client-centered care? • Discuss the use of information systems, communication methods, and a decision making-ability with culture and organizational structure of the agency. • Obtain an organizational chart from your health care setting and prepare to discuss the various lines of communication and reporting. Identify what you observe to be the formal and informal reporting lines and look at issues of power and control, as well as who the real leaders in this organization are. How are the social and cultural influences of your community integrated into the delivery of care in your organization? • How do generational differences influence the organizational culture of the workplace? --------------------------------------------------------- NUR 492 Assignment Risk Management Nursing Documentation (UOP Course) For more course tutorials visit www.tutorialrank.com Tutorial Purchased: 4 Times, Rating: A+ Prepare a 900- to 1,250-word paper on a current risk management issue at your facility. • Include the steps that have been set in place or discussed to address the issue. • Discuss how your agency determined a path to remedy the problem. • Search the literature and provide three sources that identify valid methods adopted by other facilities to address the same problem. • Compare your results to the process being developed at your agency. • Be sure to use academic references, no fewer than 2-3 Format......

Words: 684 - Pages: 3

Nur 492 Academic Professor / Tutorialrank.Com

...NUR 492 Entire Course (UOP Course) For more course tutorials visit www.tutorialrank.com NUR 492 Assignment Human Resources Policy PowerPoint (UOP Course) NUR 492 Assignment Risk Management Nursing Documentation (UOP Course) NUR 492 Assignment Organizational Structure and Culture Paper (UOP Course) NUR 492 Process Improvement and Change Project Presentation (UOP Course) NUR 492 Assignment Interview of Health Care Leader (UOP Course) --------------------------------------------------------------------------------------------- NUR 492 Assignment Human Resources Policy PowerPoint (UOP Course) For more course tutorials visit www.tutorialrank.com Perform a literature search on a human resource law or policy. Some possible topics are absenteeism, work place injury, or the Americans with Disabilities Act of 1990. Prepare a 8-10 slide Microsoft® PowerPoint® presentation with speaker notes on one of the topics and describe the law or policy and how a workplace of your choosing would be able to demonstrate compliance with it. Your presentation should include the following: Human Resource Policy Presentation Perform a literature search on a human resource law or policy. Some possible topics are absenteeism, work place injury, or the Americans with Disabilities Act of 1990. Prepare a 8-10 slide Microsoft® PowerPoint® presentation with speaker notes on one of the topics and describe the law or policy and how a...

Words: 533 - Pages: 3

Nur 492 Slingshot Academy - Snaptutorial.Com

...NUR 492 Entire Course For more classes visit www.snaptutorial.com NUR 492 Assingment Human Resources Policy Powerpoint NUR 492 Assignment Risk Management Nursing Documentation NUR 492 Assignment Organizational Structure and Culture Paper NUR 492 Process Improvement and Change Project Presentation NUR 492 Assignment Interview of Health Care Leader --------------------------------------------- NUR 492 Process Improvement and Change Project Presentation For more classes visit www.snaptutorial.com I need to preview an example to make sure I am on the right track.instructor is of no help what so ever. thanks  prepare a 10 -15 slide microsoftpowerpoint presentation with speaker notes. Slide count does not include the title or reference slides and include the following topics (NOTE: you must incorporate each item below in the slide header in your final presentation to prevent 1 point loss per missing item): *introduction *Identificiation of problem or process to be changed *Need for the change or enhancement, including driving forces such as: -regulatory, such as OSHA mandate -Benchmarking -Improved efficiency -Patient satisfaction -life safety issue *timeline *methodology used *what change theorist and leadership style you would incorporate *Research literature to support proposed change process *PDAC TQM cycle, implementation strategies, and evaluation process. Note: You may use Six Sigma or another Total Quality Management (TQM) method if it...

Words: 762 - Pages: 4

Nur 492 Tutorial Absolute Tutors / Nur492Tutorial.Com

...NUR 492 Assignment Interview of Health Care Leader FOR MORE CLASSES VISIT www.nur492tutorial.com Prepare a 1250-1500 word paper Interview a health care leader of your choosing. Discuss roles, responsibilities of leadership and management ________________________________________________________ NUR 492 Assignment Organizational Structure and Culture Paper FOR MORE CLASSES VISIT www.nur492tutorial.com Obtain a nursing organizational chart for your agency, department, or service area. Write a 1,050- to 1,400-word paper in which you address the following: • Identify the type of organizational structure. • How does the structure create an environment of support for client-centered care? • Discuss the use of information systems, communication methods, and a decision making-ability with culture and organizational structure of the agency. ________________________________________________________ NUR 492 Assignment Risk Management Nursing Documentation FOR MORE CLASSES VISIT www.nur492tutorial.com Prepare a 900- to 1,250-word paper on a current risk management issue at your facility. • Include the steps that have been set in place or discussed to address the issue. • Discuss how your agency determined a path to remedy the problem. • Search the literature and provide three sources that identify valid methods adopted by other facilities to address the same problem. • Compare your results...

Words: 614 - Pages: 3

Nur 492 Tutorial Real Education/Nur492Tutorial.Com

...NUR 492 Entire Course FOR MORE CLASSES VISIT www.nur492tutorial.com NUR 492 Assingment Human Resources Policy Powerpoint NUR 492 Assignment Risk Management Nursing Documentation NUR 492 Assignment Organizational Structure and Culture Paper NUR 492 Process Improvement and Change Project Presentation NUR 492 Assignment Interview of Health Care Leader **************************************************** NUR 492 Assignment Interview of Health Care Leader FOR MORE CLASSES VISIT www.nur492tutorial.com Prepare a 1250-1500 word paper Interview a health care leader of your choosing. Discuss roles, responsibilities of leadership and management ************************************************************************************* NUR 492 Assignment Organizational Structure and Culture Paper FOR MORE CLASSES VISIT www.nur492tutorial.com Obtain a nursing organizational chart for your agency, department, or service area. Write a 1,050- to 1,400-word paper in which you address the following: • Identify the type of organizational structure. • How does the structure create an environment of support for client-centered care? • Discuss the use of information systems, communication methods, and a decision making-ability with culture and organizational structure of the agency. ************************************************************************************* NUR 492 Assignment Risk Management Nursing Documentation FOR MORE...

Words: 361 - Pages: 2

Nursing Resistance of Electronic Documentation

... sufficent collection of data from electronic documentation and evidence-based practice. Nurse resistance has a profound effect on reimbursment and can be reduced through training and support. References Bakken, S. (2001). An Informatics Infrastructure Is Essential for Evidence-based Practice. Journal of the American Medical Informatics Association(8), 199-201. Blumenthal, D., & Tavenner, M. (2010). The Meaningful Use Regulation for Electronic Health Records. New England Journal of Medicine, 501-504. Childers, K. R. (2005). Paying the price for poor documentation. Springhouse Corporatin. Choi, E., Chung, E., & Lee, H. (2006). Users' Satisfaction on the Electronic Nursing Record. In Studies in Health Technology and Information (p. 855). IOS Press. Chow, S. K., Chin, W.-Y., Lee, H.-Y., Leung, H.-C., & Tang, F.-H. (2011). Nurses' preceptions and attitudes towards computerisation in a private hospital. Journal of Clinical Nursing, 1685-1696. Sharifian, R., Askarian, F., Nematolahi, M., & Farhadi, P. (2014). Factors influencing nurses' acceptance of hospital information systems in Iran. Health Information and Management Jouranl, 43(3), 23-28. Simpao, A. E., Ahumada, L. M., Galvez, J. A., & Rehman, M. A. (2014). A review of analytics and clinical informatics in health care. Journal of Medical Systems. Wright, A., Feblowitz, J., Samal, L., McCoy, A. B., & Sittig, D. F. (2014). The Medicare Electronic Health Record Incentive Program: Porvider......

Words: 1514 - Pages: 7

Relationship Between Nursing Documentation and Patients' Mortality

...Relationship Between Nursing Documentation and Patients’ Mortality Emily Bosco Nursing 134 Mrs. Simmons/ Dr. Gusiti November 2, 2013 Relationship Between Nursing Documentation and Patients’ Mortality For the first time, the way a nurse documents have been linked to a patient’s mortality. The title of this article is called the Relationship Between Nursing Documentation and Patients’ Mortality. The focus of this study is to identity the association with nurse’s optional documentation and hospital mortality and how they are benefit each other for a set of risk- stratified acute care patients. Having an early recognition of a patients status followed with effective communication by the health care members has lead to a decrease in hospital mortality. It was found that nurses document optional data in the electronic health record (EHR) flow sheets. That is where they record any concerns they may have and to report abnormal data. The definition of optional documentation is recording vital signs more often than required, and entering in comments in the textbox that is associated with the data findings. The reason for optional documentation is the nurses concern for the patient’s current status deteriorating and leading to death. Optional documentation shows the nurses general concern and surveillance for a patient who may be dying. Then by documenting using the EHR it enables the patterns of documentation that are clinically significance to be detected and alerts the...

Words: 551 - Pages: 3

Nur 492 Tutor the Power of Possibility/Nur492Tutordotcom

...NUR 492 Assignment Interview of Health Care Leader FOR MORE CLASSES VISIT www.nur492tutor.com Prepare a 1250-1500 word paper Interview a health care leader of your choosing. Discuss roles, responsibilities of leadership and management …………………………………………………................ NUR 492 Assignment Organizational Structure and Culture Paper FOR MORE CLASSES VISIT www.nur492tutor.com Obtain a nursing organizational chart for your agency, department, or service area. Write a 1,050- to 1,400-word paper in which you address the following: • Identify the type of organizational structure. • How does the structure create an environment of support for client-centered care? • Discuss the use of information systems, communication methods, and a decision making-ability with culture and organizational structure of the agency. • Obtain an organizational chart from your health care setting and prepare to discuss the various lines of communication and reporting. Identify what you observe to be the formal and informal reporting lines and look at issues of power and control, as well as who the real leaders in this organization are. How are the social and cultural influences of your community integrated into the delivery of care in your organization? • How do generational differences influence the organizational culture of the workplace? …………………………………………………................ NUR 492 Assignment Risk Management Nursing Documentation FOR MORE CLASSES VISIT...

Words: 945 - Pages: 4

Organizational Paper and Culture Paper for Nur/492

...Health Care Leader Interview Tasmiyah Gaskins NUR/492 June 1, 2016 Catherine Amitrano Health Care Leader Interview The primary goal of any health care system should be to influence the quality of patients care through good nursing leadership. Effective nursing leaders are generally not born knowing how to positively affect people, their powers of persuasion are developed with a willingness to serve and old with fashion sweat equity. Attributes such as honesty, empathy, communication, flexibility, direction and conviction are some of the ingredients which comprise a phenomenal leader. During this interview I will refer to this leader as (CT) which are her initials. Henceforth, this is why I choose to interview this leader and ask the following question: Background and Role you have Today This nursing leader (CT) began her career with humble beginnings. She started out as a certified nursing assistant and worked in this capacity for a couple of years. Due to the limitations of her current job she was compelled to go to school to become a Licensed Practical Nurse (LPN). She worked for several years as LPN until her children were in middle school. Work as a LPN was rewarding, However, there were restrictions on her practice- depending on what facility she was working in. She stated, “I was smart enough to put in a heparin lock, but not competent enough to flush it”. This was frustrating at times and was the deciding factor for her to return to school to...

Words: 1144 - Pages: 5