Nurses Notes

Medina College

Pagadian City

MONITORING NURSES’ NOTES

ZAMBOANGA DEL SUR MEDICAL CENTER

MEDICAL WARD

In fulfilment for the requirements

In Elective II. Quality Health Care and Nursing.

Submitted by

Jeff Oliver B. Fabie

Submitted to

Sandy Joyce S. Agum, RN

August 3, 2011

II. INTRODUCTION

Effective communications among health professionals is vital to the quality of client care. Generally, health personnel communicate through discussion, reports, and records. The process of making an entry on a client record is called recording, charting or documenting. (Kozier et al, 2004, p.329)

A progress note is a chart entry made by all health professionals involved in a clients care. The client record should describe the client’s ongoing status and reflect the full range of the nursing process. Regardless of the record system used in an agency, nurses document evidence of the nursing process on variety of forms throughout the clinical record. (Kozier et al, 2004, p. 332-337).

Documentation is an essential tool to determine and evaluate the progress of the patient’s status. Nurses are expected to record everything they have done regarding the patients care. Failure to do so will give a wrong communication to the health personnel involved in the patients care. This study aims to evaluate if proper documentation is still observed today, know if every nursing procedure recorded in the nurses’ notes have been done and note any deviations from the correct and standard way of documentation.

III OBJECTIVES

The objectives of the study are the following:

• Verify the veracity of the entry made.

• Evaluate if every entry made has been/have been done.

• Note any deviations from the correct and standard way of making an entry.

IV PLAN (step by step)

Step 1: Secure note and consent from the proper authorities of the hospital.

Step 2: Talk to the Nursing Director for the proposed study and secure consent as...