These are the most significant texts to be developed recently. Anyone wanting to be a part of a positive future in nursing would do well to become as familiar with these works and use them ASAP.
This provides the basis for what nurses do, research, teach in our schools of nursing.
Documentation of the nursing process is mandated by most (if not all state Nursing Practice Acts). These languages are very computer-friendly and easily adaptable to any clinical setting. They have set the standard for the nursing profession.
Here's some thoughts that I've had for awhile. We've all been taught to practice nursing. Any nurse accepting renumeration for his/her nursing services had better have this record in place. Liability-wise, this documentaton has got to be in place.
Does your employer provide the necessary resources of time, money, staff to allow you to document this way? Is it a part of the permanent record and retreivable
from your system? Many nurses are still using cardboard Kardexes and documenting their work in pencil, only to be thrown away at the time of the patient's discharge!
Large investment houses advertised that they would take care of people's money. They employed accounting professionals (minimum of a BS degree in accounting, state certification-CPA, a professional code of ethics to safeguard the consumer and maintain a level playing field among competing companies.) Upon their arrival as new hires, they were told "Well, I know you learned all that stuff in school about honesty, ethics etc., but here's how we do it here." Years passed. We've come to find out that the folks at the top have left town with the money.
If an aduit of your patient's charts were done today to see if your patient is receiving nursing care as promised (by your state's Nursing Practce Act) and paid for by the third-party payors, would things really line up? If not, isn"t this the basis of fraud that effects almost every healthcare facility in the country? Share with me your thoughts on this.
As time goes on and policies are developed and revised at your place of work, use these as your working texts to
update your practice to be consistant with the rest of the nursing profession.
Just my opinion. Edward, IL