Premium Essay

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

Premium Essay

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

Premium Essay

Risk Management

...Risk Management Nur/492 April 1, 2013 Kendra Slatton, RN, MSN, CDE In 1996, the United States Congress enacted the Health Insurance Portability and Accountability Act (HIPAA) into law. The purpose of the law was to focus on providing greater access to health care for Americans and to address administrative activities regarding claims submissions to insurance carriers (American Medical Association, 2011). Along with streamlining the administrative process, HIPAA also guarantees patient privacy and has strict guidelines regarding how organizations can disclose a patient’s protected health information (American Medical Association, 2011). The Department of Health and Human Services promises to impose steep fines to those organizations that do not follow the HIPAA guidelines. Although many of the guidelines they are referring to have more to do with billing and coding procedures, patients’ privacy is also very important. Many facilities have educated staff extensively on the issues surrounding patient privacy. Prior to 1996, a patient’s family member could call a hospital and request the medical status of his or her loved one who was hospitalized. Currently, the patient must give express consent as to whom the staff may and may not speak with regarding their care. The rule has become to not only refrain from giving any information, but they cannot even......

Words: 1635 - Pages: 7

Premium Essay

Outcomes Management of Nursing

...Outcomes Measurement and Data Management Project: Hospital Readmissions Charmein Garner and Celeste Thomas Loyola University New Orleans Outcomes Management Project Defined Issue or Problem of Interest The selected problem of interest is hospital readmissions after being discharged from hospitals/medical facilities. Several patients enter the hospital and soon after discharge are catapulted back into the seemingly revolving doors of the hospital. Readmission rates affect all areas of healthcare. Center for Medicare and Medicaid (CMS) has targeted readmissions as a guideline of poor quality of care. Engaging patients during their inpatient admission as they transition to alternate levels of care may reduce readmission by 50% (Service, 2008). The intent of this proposed paper is to take a look at hospital readmissions rates in correlation with the patient being elderly and having a diagnosis of heart failure and assess what can be done to positively change these statistics, which increase the quality of care we as healthcare professionals provide to our patients. A Rationale for Selecting the Issue or Problem of Interest Hospital readmissions can occur throughout the patient’s transition through the healthcare system. Many times readmissions occur among those who are frail and have chronic conditions. Readmissions account for approximate 18% of Medicare patients, of this 13%, are suspected to be avoidable and are directly linked to poor quality. Quality......

Words: 1562 - Pages: 7

Free Essay

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 sisters...

Words: 3852 - Pages: 16

Premium Essay

Risk Management

...Public trust is a major concern when it comes to managing risk policies. The base of risk management is necessary for the company to grow and move into its full potential. Weak policies can lead to vulnerabilities in our infrastructure and network allowing potential threats to the integrity of the company. Credit card information, confidential information, wireless connections and other assets can all be taken without proper management. What does risk management do for us and how does it address future security breaches and more importantly how does it reduce the risks. Risk management is a decision which determines which types of vulnerabilities the company can be susceptible to, what kind of impact different vulnerabilities have, and lastly an action plan to control the impact of how many assets get affected. It also involves identifying what kind of vulnerabilities there are and where they are within the company. The risk is high in our establishment due to us housing credit card information and personal data. A risk assessment to determine what is within our environment should be completed as it will give us a broader idea of what to expect if a system gets compromised. A documented process involving senior staff and management should be considered moving forward. A risk management policy as well as a dedicated team designed for risk management should also be implemented. Following this general infrastructure will help in organizing what assets we have and who would......

Words: 511 - Pages: 3

Premium Essay

Nursing Management

...WEEK ONE: LEADING, MANAGING & FOLLOWING (Chapter 1, p. 3-21) 1. Relate leadership and other motivational theories to behaviors that serve as important functions of professional nursing. a. Leadership theories i. Trait theories: 1. 2. Innate leadership skills: being born with a certain set of physical and emotional characteristics for inspiring others to reach a common goal ii. Style theories: 3. 4. How leaders behave in certain environments and situations. a. Democratic: you care about what others think b. Lasae faire: no structure; people can do what they want c. Authoritarian: you are in charge iii. Situational-contingency theories 5. 6. These theories consider the challenge of a situation and encourage an adaptive leadership style to complement the issue being faced. Assess, assess, assess 7. You are typically democratic; you assess the situation and change your style based on what the situation is. iv. Transformational theories 8. 9. Inspires, motivates, empowers, mentors, provides intellectual stimulation and promotes creativity b. Motivational Theories v. Hierarchy of needs 10. 11. Low level needs will always drive behavior before higher levels needs can be addressed. For example, pain level, nutrition...

Words: 4382 - Pages: 18

Premium Essay

Nursing Management

...Being Influential Janean Palaruan 3163435 Athabasca University NURS 432 Management and Leadership in Nursing Practice Lorena Stewart Not all individuals are naturally speaker. Some people have great ideas, but are unable to articulate it properly. Contrarily, there are others who are excellent in presenting their ideas. As a nurse, being able to express, articulate and explain ideas are keys to be able to share their knowledge to other health care professionals and influence others. It is also an acquired ability that helps nurses provide information to patient and their family on a mutual language. In fact, according to Kozier (2010), becoming influencing is “exercised through persuasion and excellent communication skills” (p. 540). As mentioned above, not all nurses are able to communicate properly. This paper will demonstrate how I can influence others into speaking out. My Message The subject of my message is about the Bill 10. This bill was recently passed by the government of Quebec on February 7, 2015 (National assembly, 2015). This bill is an “act to modify the organization and governance of the health and social services network, in particular by abolishing the regional agencies” (National Assembly, 2015, p.1). Basically, this bill will eliminate the bureaucracy section of the health care system and merging 182 institutions to 19 regional institutions in order to save money. However, this will affect not only the nurses, but also patients’ rights. I......

Words: 1114 - Pages: 5

Premium Essay

Risk Management

...Risk management In this section a summarized position of various risks facing DBBL while conducting its business and operations and steps taken by the Bank to effectively manage and mitigate such risks are discussed. RISK MANAGEMENT FRAMEWORK Risk is defined by DBBL as risk of potential losses or foregone profits that can be triggered by internal and external factors. Therefore, the objectives of risk management are identification of potential risks in our operations and transactions, in our assets, liabilities, income, cost and off-balance sheet exposures and independent measurement and assessment of such risks and taking timely and adequate measures to manage and mitigate such risks within a risk-return framework. In DBBL, only calculated risks are taken while conducting banking business to strike a balance between risk and return. Risk is clearly identified, mitigated or minimized and if possible eliminated to protect capital and to maximize value for shareholders. It is also ensured that on-balance sheet and off-balance sheet risks taken by the Bank are consistent with risk appetite and short term as well as long term strategic objectives of the Bank. A wide range of tools and techniques are used to address & mitigate all kinds of inherent and potential risks in banking operations. The Bank attaches highest priority to establish, maintain and upgrade risk management infrastructure, systems and procedures. In this regard, sufficient resources are allocated to......

Words: 2576 - Pages: 11

Premium Essay

Risk Management

...JIT2 (Risk Management): Task 1A Our firm has been hired as a consultant, the first task my team and I have been assigned is to create and present to management both a risk management and a business contingency plan for our client. Both the legal and IT departments have expressed their concerns regarding the ethical use and protection of sensitive data, customer records, and other information systems content of both the firm and the client. In an effort to follow the company’s goal of each project building employee confidence and job satisfaction, the team has been allowed to select our first client. The client we choose can be a former or current employer, any local business, any nationally or internationally held publicly traded or privately held company. The one prerequisite is that the client operate globally in at least one aspect of it business. To help ensure anonymity and security any information that could be considered confidential, proprietary, or personal in nature will be excluded. No actual names of people, suppliers, the company, or other identifiable information will be included. In addition every effort will be made to ensure fictional names used will be obscure as possible. Company-specific data, including financial information, will be addressed in the most general and generic means possible when appropriate. Per the client’s request will address the following items: A. Generate a risk register that includes eight valid risks faced by the client.......

Words: 2097 - Pages: 9

Premium Essay

Nursing Resistance of Electronic Documentation

...Resistance of Nurses in Use of Electronic Documentation The field of health information technology for nursing is rapidly growing. Advancements in electronic documentation for health care, such as the electronic medical record (EMR), can be an overwhelming addition to the workload of nurses. There is resistance by nurses in use of electronic documentation (Sharifian, Askarian, Nematolahi, & Farhadi, 2014). It is this writer’s opinion that nurses are under informed regarding the rationale for changes taking place in documentation and the implications. The purpose of this paper is to provide nurses with the basics of the Federal regulations outlined in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) that require electronic documentation to be compliant and receive reimbursement. It also reviews how data are collected to determine the reimbursement for care (meaningful-use) and its role in evidence-based practice (Wright, Feblowitz, Samal, McCoy, & Sittig, 2014). Included is a review of the negative impact resistance generates on health organization reimbursement and the relevance it has on nurse staffing, jobs, wages, and satisfaction, along with, evidence reinforcing the training and support of nurses as a means to promote proper use of electronic documentation and increase user satisfaction. Federal Laws and Requirements for Compliance Health......

Words: 1514 - Pages: 7

Premium Essay

Falls and Risk Management

...Falls and Risk Management Margaret Simon NUR 492 April 25, 2016 Dr. Rachel Gonzales Falls and Risk Management In the hospital setting falls are prevalent for various reasons. According to Sullivan (2013), “Risk management is a component of quality management, but its purpose is to identify, analyze, and evaluate risks and then develop a plan for reducing the frequency and severity of accidents and injuries” (p. 77). This paper will address falls as a risk management issue; discuss methods to identify patients as a fall risk, methods to implement to reduce falls, and how to inform all staff of seriousness of fall issue. Furthermore, a comparison of three other facilities and their methods will be discussed and compared to the VA hospital's plan of action. Hospital Plan for Identifying Falls Every patient that enters the hospital is required to have a fall assessment on the admission, and if the staff feels a patient's status has changed, it is completed again. The fall assessment template addresses cognitive status, hearing and vision issues, and gait and balance problems. Other information collected is his or her ability to use assistive devices such as canes, walkers, and crutches. Other information gathered is a medication list, a history of falls, and medical conditions such as vertigo. Another major issue is the environment at home, not enough lighting, rugs, stairs, and animals. In the hospital setting the number of falls is increasing......

Words: 1311 - Pages: 6

Premium Essay

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

Premium Essay

Organizational Paper and Culture Paper for Nur/492

...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 further her nursing career.......

Words: 1144 - Pages: 5

Premium Essay

Importance of Documentation in Nursing

...When talking about documentation, there is one powerful saying that comes into my mind which I heard a lot of times from my clinical instructors back home – “if it is not in writing, it did not happen”. For me, the message of this expression is about using documentation as evidence. Document in general as defined by American Heritage Dictionary of the English Language (2011) is a written or printed paper and can also be recording or photograph that bears the original, official, or legal form of something that can be used to furnish decisive evidence of information. As nurses, we deal with lots of legal matters since we are handling lives. Our documentation will save us from litigation. If we cannot present evidence of an event or activity then everything we say will just be speculations, which are not accepted in the court. I believe this is the most important reason why we need to document. In nursing practice, College of Nurses of Ontario (CNO) states that “documentation—whether paper, electronic, audio or visual—is used to monitor a client’s progress and communicate with other care providers. It also reflects the nursing care that is provided to a client.” (2008, pg. 3) Personally, I could not imagine caring for patients without documenting the assessment, the interventions or implementations, the patient’s response to the care provided and other necessary information. I will not be able to memorize what was done in the whole shift and endorse the care I provided to......

Words: 671 - Pages: 3

Premium Essay

Risk Management

...Risk Management Health care institutions are the centers for different kind of healthcare services, so when patients and their families come for check-ups, surgeries, acute hospitalizations, tests, minor procedures, etc. they expect quality care and positive outcomes. Issues come up when patients’ expected outcomes are not realized due to one reason or another. Factors that may prevent positive outcomes in patient care may be quality management issues or risk management issues. Before a full introduction and analysis of risk management in my place, one has to understand quality management and risk management. In terms of quality management, they are issues that arise in the work place as a result of poor management and need to be improved on. They are more prevention oriented (Sullivan and Decker, 2009). In the case of risk management, it is about issues that are problematic throughout a health organization and may lead to poor patient outcomes. As described by Sullivan and Decker (2009), “risk management’s purpose is to identify, analyze, and evaluate risks and then to develop a plan for reducing the frequency and severity of accidents and injuries” (p. 84). Risk management is not about monthly, quarterly or yearly assessment and improvement of programs, but a daily assessment of issues that arise in the work place that may lead to bigger problems if not corrected. Current risk management issue at my work place. The main current risk management issue in my place of......

Words: 1761 - Pages: 8