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Nursing documentation and communication

Nursing documentation and communication

Nursing documentation and communication

The purpose of this assignment is to allow you the opportunity to explore various research methods related to change management within your workplace. The Change Management Capstone Project is a framework that describes a series of 4-steps that encompasses the action research process and follows the Nursing Process.

Step 1: Diagnose & Analyze the Issue

Step 2: Research Potential Solutions

Step 3: Develop an Action Plan

Step 4: Evaluation.

The Change Management Capstone Project should be based on your place of employment. You should assess your place of employment and identify an area that needs improvement or look for an opportunity to impart change to help improve unit function (this was done earlier in the semester). You will finalize the Change Management Capstone Project in the NURS 4457 Leadership & Management course in your final semester. Please note, you will not be expected or permitted to implement this project. For this assignment, you will complete

Step 1: Diagnose & Analyze the Issue. Use the qualitative research/clinical questions you created earlier in the semester while developing this assignment. Furthermore, give a description of the background of the issue you selected. Answer key questions such as: a) What is the issue or opportunity at hand? b) What information do I need in order to comprehend the issue? c) How does the issue affect organizational structure (e.g., political, economic, social, ethical considerations)? d) Who needs to be involved on the exploration team? e) How will you select team members and why? Please include graphics (circle graph, bar graph, histogram, line graph, etc.) to help explain the project focus. You will also need to create a PICOT Worksheet Click for more options for each of the references used in this assignment.

Please write a five-page paper (excluding cover sheet and references), using APA citation and at least three references. The PICOT Worksheet Click for more options will not be included in the page count; they should be included as an appendix at the end of your paper. Upon receipt of the assignment, your submission will automatically be submitted to SafeAssign, the premier plagiarism checker for Blackboard for proper citation and reference.


Nursing documentation and communication


Changes are essential in the healthcare system because they lead to the transformation of healthcare processes which in turn lead to the delivery of quality treatment and general care. Health institutions involved in the continuous change processes often ensure effective patient outcomes and improvement in the quality of care. There are different problems associated with healthcare delivery processes. These problems can be solved through introducing changes in different departments. Changes can range from the incorporation of evidence-based practices in the treatment processes to the implementation of technological practices to facilitate the efficiency of diagnosis and treatment processes (The Royal Children’s Hospital Melbourne, n.d). Most healthcare institutions operate throughout the day, as a result nurses and other healthcare professionals need to work in shifts to ensure that there is continuity in service delivery to the patients. These processes requires the implementation of important changes. In my place of work, there is always a challenge in the management of patient’s data, a scenario that often leads to the increased confusion and medication errors. The change process should therefore involves the incorporation of effective documentation system to reduce clerical errors, enhance the storage of patient information and enhance the delivery of quality care. Nursing documentation and communication.

Documentation in Healthcare Practices

Documentation in healthcare is a critical part of you nursing. It can really elevate or diminish your character in the court of law. If it is not documented then it is not done, that is motto that every healthcare professional should live by when working on a day to day basis. Nursing documentation is essential for good clinical communication (LoBiondo-Wood & Haber, 2018). Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care. To ensure quality healthcare delivery in different healthcare institutions, ensuring effective documentation is essential.

Effective documentation often ensure that patient’s data and the operational processes are well documented for future references. Also, with the increase in the number of complications among the patients, documentation will always ensure that there is continuity in the treatment or care processes delivered. When healthcare records are well documented, it becomes easier of the subsequent healthcare workers to identify the right approach to take in the treatment process. Quality documentation expresses that the exact information about the patient. It is clear and concise without subjective opinions and false data. It increases communication among all entities working with the patient, and decreases clerical errors. Nursing documentation and communication.

Information Needed to Comprehend the Issue

The implementation of the documentation in the healthcare system requires the analysis of different factors. To comprehend the issue of documentation, there is the need for the implementation team to consider previous processes that have been undertaken on the similar processes. For instance, there is the need for the team to benchmark with other organizations that have undertaken a similar change process. Other forms of information that are needed to comprehend the issue of documentation are the forms of documentation that are appropriate in the healthcare system (Kurniawandari, Fatimah, & Listiyanawati, 2019). Depending with the organization or an institution, there are different types of documentation that are appropriate in the operational processes. With the increase in the use of technology, databases and the electronic health record systems are important forms of documentation that can be considered (Scruth et al., 2020). With the use of technology in different sectors, more people rely on technology to perform different tasks. In my health care institution, there is the need to create a technological change to increase the increasing cases of medication errors that often results from the poor record keeping. The change, implementation of the EHR system may come with a lot of challenges including lack of the infrastructure, lack of healthcare professionals skilled in nursing informatics as well as the opposition from other members of the team who are not pro-change. However, for the successful implementation of the change processes, there is always the need for the management to effectively organize the resources required.

How the Issue of Documentation Affect Organizational Structure

Implementation of effective documentation is important in ensuring an establishment of efficient organizational structure. In other words, the introduction of efficient documentation processes will leads to the definition of roles of each department, a scenario that will enhance interprofessional collaboration between the management, healthcare professionals, and the entire stakeholders within the institution. In other words, the issue of documentation will improve he economic, political, and social structure. The idea of documentation will also enhance the establishment of ethical consideration in the course of operation. The introduction or a change in the documentation processes will greatly transform the organizational structure by ensuring that there is seamless communication and sharing of information. The above scenario will in turn lead to the development of an effective organizational structure with effective economic, political, social and ethical consideration.

Exploration Team

To ensure effective implementation of the documentation process, there is the need to incorporate different stakeholder within the organization. The process of change will impact every member of the organization and this explains the need to involve different members into the team. Nursing leadership will be incorporated in the exploration team to provide the analysis on how the nursing professionals will adjust to the change process. Also, the management, policy makers, and the patients will be involved in the implementation of the documentation process to ensure that there is effective outcomes. In most cases, management team have the experience and knowledge on the change processes, as a result, they can provide important directions on what need to be incorporated in the change process. Nursing professionals, especially those who have been engaged in the documentation processes will be able to provide effective approaches that ought to be followed in the implementation of the change process, documentation.

Selection Process of Team Members

The selection process will involve identification of the individuals with elaborate knowledge on the documentation processes. Also, when selecting members of the exploration team, there will be the need to consider professionals with elaborate knowledge on the change process. The main focus of the project is to determine effective ways of determining effective approaches in the implementation of change, introduction of implementation processes in the hospitals and other healthcare institutions. Before undertaking the change process, benchmarking will be done to ensure that only individuals will appropriate knowledge on the documentation processes are incorporated in the implementation or exploration team.


The Royal Children’s Hospital Melbourne. (n.d.). Retrieved February 07, 2021, from https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/nursing-documentation-principles/

Scruth, Elizabeth Ann PhD, MPH, CCNS, CCRN, FCCM (2020) Quality Nursing Documentation in the Medical Record, Clinical Nurse Specialist: November/December 2014 – Volume 28 – Issue 6 – p 312-314 doi: 10.1097/NUR.0000000000000085

LoBiondo-Wood, G. & Haber, J. (2018). Nursing Research Methods and Critical Appraisal for Evidence Based Practice. (9th ed). St. Louis, MO: Elsevier. (Page 150-155).

Kurniawandari, E., Fatimah, F. S., & Listiyanawati, M. D. (2019). Implementation of Documentation of Nursing Care in Wates Hospital. Jurnal Ners dan Kebidanan Indonesia6(2), 68-75. Retrieved from: http://ejournal.almaata.ac.id/index.php/JNKI

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