Reflective essay on nursing documentation

reflective essay on nursing documentation

Norman, S and Schober. This would be hard to do if you did not feel empathy for patients. After a discharge date was set the nurse made appropriate arrangements for transport via an ambulance and liaised with a family member in order ensure a safe arrival at home. It was documented and handed over that my client had appeared to have progressed in all that was set. Nursing and Midwifery Council (2002) Code of Professional Conduct. Sometimes nurses do not have enough time to read charts and look up common problems during their shift. The fact that the MDT were based within the same unit allowed a more timely advantage for both patient and staff, allowed maximum communication to all concerned and worked well in relation to discharge planning. Since the entire MDT was based in the same unit, the communication was excellent.

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On reflection, I felt this was a good idea, particularly for myself as a student to refer to, however it could present an opportunity for care plans to become less individualised should they be used incorrectly, which consequently. Involvement and relationship with another is both necessary for the enactment of orientation and development of the therapeutic relationship (Glasser, 1965, cited by Perry et al, 1991). Using this model, I was able to reflect in structured and effective way. Furthermore, my action plan will include improving my knowledge and awareness of working with young people as a nursing professional. According to the Australian. It will minimise duplication of assessments by agencies and save older people from having to repeat their personal details reflective essay on nursing documentation and needs to a range of professionals. Evaluation This is the final stage in the nursing process, which occurs continuously while providing care. Due to the nature of the ward the new single assessment process has recently been introduced.

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(1998) The Skilled Helper: A problem-management approach to helping. This is to ensure patient autonomy but also to give Mary a clear picture of what will be expected of her during her rehabilitation period. London: Balliere Tindall, Mosbys Nurses Pocket Dictionary. (1976) Doctors talking to patients. However, I did forget certain aspects of the physical examination and had to be prompted by the. (1988) Learning by Doing: A guide to teaching and learning methods. On reflection, I found that the care plans were maintained well. Conclusions : this step explores the potential alternatives that may be used to deal with the situation that is being reflected upon. Based on the reasonably lengthy history of the acne, the presence of acne on the face and the negative emotional effect that the acne was having, a three month dosage of oxytetracycline was prescribed for the patient. (1983) Understanding the Nursing Process. Visit m to see how we can help you! Reflective in nursing practice, reflection plays an important role in nursing practice. References, byrne, P,., long, B, E,.

Helping others a great joy, Nursing my passion Men, women, and children Arrived sick and sad, retuned healthy and smiling Seeing people smile, it is a joy that cannot be explained. Assessment Mosbys Nurses Pocket Dictionary defines assessment as An appraisal or judgement made about one particular situation or circumstances, A stage of the nursing process involving the collection of information and data relating to patients and their healthcare needs (Mosby 2002,.31). Vol 40 (3) p346-354 Source: Essay UK - http www. Additionally, I will continue to develop my consultation and history taking skills by using Byrne and Longs (1976) consultation model to assist my practice and aid future development. (2010) Perceived barriers and facilitators to mental health help-seeking in young people: a systematic review. Rodrigo, september 2, 2016, writePass, essay. Both myself and my mentor introduced ourselves to Mary who was sitting at her bed side in a cubicle. It is safe to say that the stages in the nursing process are not in complete isolation from reflective essay on nursing documentation each other, I found from observing care given that each stage overlaps the next. The needs identified were specifically related to mobility and pain, both of which affect ALs. (2006) Mosbys Guide to Physical Examination. An Enquiry into Attitudes of Qualified Nursing Staff towards the Use of Individualised Nursing Care Plans as a Teaching Tool.

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You May Also Find These Documents Helpful. Holistic care is an approach to healthcare which treats the individual as a whole person in relation to their needs (Hinchliff et al, 1998). Hand over was a good reflective essay on nursing documentation source of information used in order to find whether the care being given is right for the patient. New York: Basic Books. Wimpenny (2002) The Meaning of Models of Nursing to Practising Nurses. This information only served to make me feel more anxious and I wished that I had bought this up with the patient. Oxford: Further Education Unit. The patient described the negative effect that the acne was having. Hayter (2005) also found that young people had serious concerns regarding confidentiality, especially during busy times at the clinic. References Archibald, G (2000).

London: hmso egan,. Public Health Nursing, 22(4. Get Access To The Full, essay 300, materials Daily 100,000 Subjects 2000 Topics. Journal of Advanced Nursing. Documentation, we can write a custom essay, according to Your Specific Requirements, order an essay. The patient disclosed that he had begun to get spots at around age 14 when he had started puberty and that it had begun to make him feel extremely self-conscious. Analysis : this step delves even deeper into reflection on the event and encourages the nurse to break the event down into smaller episodes in order to facilitate analysis. I think that the social aspect of the ward helped a great deal. In particular, the authors found that directly asking about suicidal thoughts should be encouraged during consultations with young people. This way, young people can access the information if they perhaps feel too embarrassed to talk about. How well does the client mobilise? It is also seen in Owen(2005) that even when there is no change in the patients condition documentation should be carried out.

This will allow me to increase the tools and skills I have for dealing with young people with complex needs. Self-reflection and reflection upon events that happened within a work environment are important for individuals within the nursing profession (Paget, 2001). (2006) have found that young people with acne are at an increased risk of suicide and that attention must be paid to their mental reflective essay on nursing documentation health. At this point and in order to encourage a timely discharge my client and her family were informed of a home visit. With documentation, nurses are able to clearly describe the clients current health status and what interventions should be carried out and if the interventions that were carried out benefitted the client.

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Get help with your essay today, from our professional essay writers! Daws (1998) agrees that the nursing care plans play a vital role in promoting a holistic reflective essay on nursing documentation and individualised approach to care delivery and providing an essential tool for documenting needs and preferences. I have become more efficient in collecting information from the client and utilising it appropriately in order to care for the client in a holistic way. During the planning phase, the nurse applies the skill of problem solving and decision making. To care for a person holistically requires ongoing assessments utilizing knowledge, attitudes and skills. The NSF for Older People (2001.3) defines intermediate care "to provide integrated services to promote faster recovery from illness, prevent unnecessary acute hospital admissions, support timely discharge and maximise independent living". Archibald (2000) believes evaluation should take place in collaboration with the patient and family. I used skills in observation, open ended questions and listening in an attempt to retrieve as much information possible, particularly in Activities of Living.

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I plan to show an understanding of holistic care and how it is used in each stage of the nursing process. However, under normal circumstances I would assess the patient and refer them to the MO if I was concerned about their condition, in order for a decision to be made. A Post Modern Nursing Model. The ward held a care plan file, which held care plans for a range of different problems. Step Six (Action Plan there are a number of elements to my action plan. Although with more practice such incidence would be reduced. Essay, topic:, Sorry, but copying text is forbidden on this website! The action plan is put into place in order to deal more effectively with the situation if or when it may arise again. Collaboration between the Multidisciplinary Team and working closely with patient and family enabled outcomes to be achieved. Journal of Clinical Nursing, 10(2. Step Four (Analysis on reflection, being able to relate to the patient increased my ability to deal more effectively with the situation. Nursing Children and Young People, 24(3. It can be the standing evidence in the court of law when a nurse is subjected to a malpractice case as mentioned earlier by Iayer (2001).

The theme of this reflection will cover the development and application of care, showing empathy, communication and interpersonal skills to create and maintain. After the consultation I did some research into the effects of acne in young people. Hayter (2005) has found that young people accessing health clinics put a high value on a non-judgemental approach by health staff. Reflection-in-action is a deeper and more interactive form of reflection that encourages individuals to observe and reflect on past situations from the point of view of themselves and of others around them at the time of the event. The experience also helped me realise that I need to actively search out training and learning opportunities regarding working with young people with mental health issues. On gathering individualised data, it then must be interpreted. I also felt regret and guilt. Weekly MDT meetings reflective essay on nursing documentation were held, which allowed the team as a whole to discuss plans of care.

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Implementation The Oxford Dictionary for Nurses (1998,.313) defines implementation as "the stage of the nursing process in which the patients individual care plan is utilized and executed, in collaboration with other members of the healthcare team". This paper is going to reflect a serious incident which happened in a psychiatric geriatric ward of mental health hospital. London: Department of Health. All of the contents are legal documents and can be referred to by health professionals who participate in the care being given but can also be viewed by Mary and her family. In a review of the literature, Gulliver, Griffiths and Christensen (2010) found that young people perceived embarrassment and stigma as barriers to accessing healthcare. I regretted not referring the patient onwards for emotional support and for not exploring the psychological impact of the acne in more detail.

The importance of documentation, documentation, a critical way of determining the standard of care rendered to a patient to defend nursing action(nurse together,2010).This agrees with the anmcs competency standard.1 where it states that Practices in accordance with legislation affecting nursing practice and health care. New York: Harper Row, Hinchliff,. You can view samples of our professional work here. Evaluation : this step encourages the nurse to make their own judgement about the event and to consider what went well and what went less well about the event. Reflective, practitioner: how professionals think in action. (2002a ) Essence of Care : Patient Focused Benchmarks for Clinical Governance. Icat follows up referrals from both acute and community settings and assessments are made relating to clients physical, social and mental health. Wimpenny (2001) agrees stating "It is certainly the best known and most widely used model in this country". All input from therapy staff was documented by reflective essay on nursing documentation form of report and handed over to nurses on completion. This experience has taught me the importance of holistic care in relation to the nursing process and how an effective therapeutic relationship between patient and healthcare professional allows more information to be retrieved, thus creating a more precise and individualised care plan. To re-assure young patients, I may ask them to sign a confidentiality form, which I will also sign in front of them. The anmcs(2008) code of ethics value statement 7 supports this in its explanation that all documentation is a record that cannot be changed or altered other than by the addition of further information. Alfero-Lefevre, R (1998) Nursing Process: A Step by Step Guide.

The questions posed by assessing in the individuality component of the model (such as how, how often, why and when) furnished information not only about the way in which the person carried out each activity of living but. Vol 28 (1) p77-85. Oxford: further education unit, oxford polytechnic seidal, H,., ball, J,., dains, J,., benedict, G,. During the consultation I felt anger toward the patients peers who had teased him. The process can be broken down into six key steps: Description : this step explores the context of the event and covers fine details such as who was present at the event, where it happened and what happened. The patient could have chosen to go on suffering and could have chosen not to open up and talk about the problems his acne was causing. Tasks were allocated to each member of the team on specific days at specific times. This would prove to the MDT whether her progression in hospital reflected on her own living environment, therefore determining an expected discharge date and which services/equipment if any are needed to ensure the discharge is safe. In addition to providing medication to get to the biological and physiological roots of the problem, on reflection I think it would have been beneficial to the patient to have provided information about charities that offer self-esteem and confidence building. However there could be many reasons for incomplete documentation such as emergency situations when a patients needs take priority (Iayer,2001).This could later cause errors in documentation as the nurse might not have remembered what time certain events might have taken place. During the consultation I had a number of feelings. In this essay the writer will analyse the importance of nursing documentation in the current health care setting. Under the supervision of the medical officer (MO) I proceeded to carry out a full assessment and abdominal examination, using Byrne and Longs (1976) model to structure the consultation.

reflective essay on nursing documentation