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    21st Century Challenges in The NSG Service

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    The document discusses 21st century challenges in nursing services, including documentation, nursing audits, and global nursing. It outlines learning objectives about discussing challenges, trends, implications, and conceptualizing implications. Specific challenges covered are electronic health records, different documentation systems, and evaluating care through audits and peer review. Success requires accurate documentation.

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    21st Century Challenges in The NSG Service

    Uploaded by

    Blaise
    117 views43 pages
    The document discusses 21st century challenges in nursing services, including documentation, nursing audits, and global nursing. It outlines learning objectives about discussing challenges, trends, implications, and conceptualizing implications. Specific challenges covered are electronic health records, different documentation systems, and evaluating care through audits and peer review. Success requires accurate documentation.

    Original Description:

    Nsg Service Administration; Master of Arts in Nursing; Davao Doctors College

    Original Title

    21st Century Challenges in the Nsg Service

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    The document discusses 21st century challenges in nursing services, including documentation, nursing audits, and global nursing. It outlines learning objectives about discussing challenges, trends, implications, and conceptualizing implications. Specific challenges covered are electronic health records, different documentation systems, and evaluating care through audits and peer review. Success requires accurate documentation.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    117 views43 pages

    21st Century Challenges in The NSG Service

    Uploaded by

    Blaise
    The document discusses 21st century challenges in nursing services, including documentation, nursing audits, and global nursing. It outlines learning objectives about discussing challenges, trends, implications, and conceptualizing implications. Specific challenges covered are electronic health records, different documentation systems, and evaluating care through audits and peer review. Success requires accurate documentation.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 43

    21 century

    challenges in the
    nursing service
    st

    blaise b. nieve
    nursing service administration
    davao doctors college | master of arts in nursing

    introduction

    At the end of this report, the learners will


    be able to:
    Discuss the 21st century challenges of the
    nursing service;

    learning
    objectives

    Discuss the current trends in nursing


    practice that pose challenges to the
    nursing service as a whole;
    Analyze the implications of the challenges
    and how it can be dealt with; and
    Conceptualize the implications of these
    challenges in the practice of nursing.

    21st century
    challenge in
    the nursing
    service

    Documentation
    Nursing audit
    Global nurse

    nursing

    documentatio
    n

    Discussion
    (n.) informal oral consideration of
    a subject by two or more health
    care personnel to identify a
    problem or establish strategies to
    resolve a problem.

    nursing

    documentatio
    n

    Report
    (n.) oral, written, or computerbased communication intended
    to convey information to others

    nursing

    documentatio
    n

    Record
    (n.) formal, legal document that
    provides evidence of a clients
    care and can be written or
    computer based

    nursing

    documentatio
    n

    Recording, Documenting, Charting


    (v.) process of making an entry
    on a client recordprocess of
    making an entry on a client
    record

    nursing

    documentatio
    n

    Source-oriented record
    documentatio
    n systems

    Problem-oriented record
    Focus charting (FDAR)
    Charting by exception
    Case management

    documentatio
    n systems

    Traditional documentation
    Computerized documentation

    sourceoriented
    record

    sourceoriented
    record

    sourceoriented
    record

    advantages
    convenient

    disadvantages
    sourceoriented
    record

    information about a particular


    client problem is scattered
    throughout the chart, so it is
    difficult to find chronologic
    information on a clients
    problems and progress.

    problemoriented
    record
    (POMR)

    problemoriented
    record
    (POMR)

    problemoriented
    record
    (POMR)

    problemoriented
    record
    (POMR)

    advantages
    encourages collaboration;
    the problem list in the front of the
    chart alerts caregivers to the
    clients needs and makes it easier
    to track the status of each
    problem.

    problemoriented
    record
    (POMR)

    disadvantages
    caregivers differ in their ability to use
    the required charting format;
    it takes constant vigilance to maintain
    an up-to-date problem list;
    it is somewhat inefficient because
    assessments and interventions that
    apply to more than one problem must
    be repeated.

    focus
    charting
    (FDAR)

    charting by
    exception
    (CBE)

    charting by
    exception
    (CBE)

    charting by
    exception
    (CBE)

    charting by
    exception
    (CBE)

    advantages
    eliminates lengthy, repetitive
    notes and it makes client
    changes in condition more
    obvious

    charting by
    exception
    (CBE)

    disadvantages
    presumes nurse did assess the client
    and determined what responses were
    normal and abnormal; not charted,
    not done

    case
    manageme
    nt (critical
    pathway)

    case
    manageme
    nt (critical
    pathway)

    case
    manageme
    nt (critical
    pathway)

    advantages
    promotes collaboration and teamwork
    among caregivers, helps to decrease
    length of stay, and makes efficient use
    of time;

    case
    manageme
    nt (critical
    pathway)

    disadvantages
    work best for clients with one or two
    diagnoses and few individualized
    needs;
    multiple diagnoses = difficult to
    document.

    computeriz
    ed

    documentatio
    n

    electronic health records (EHRs):


    why a challenge?

    computeriz
    ed

    documentatio
    n

    pros of EHRs
    quick access to patient data;
    computer records can facilitate a
    focus on client outcomes;
    bedside terminals can synthesize
    information from monitoring
    equipment;
    such systems allow nurses to use
    their time more efficiently;
    system links various sources of client
    information;

    computeriz
    ed

    documentatio
    n

    pros of EHRs
    client information, requests, and results are
    sent and received quickly;
    links to monitors improve accuracy of
    documentation;
    bedside terminals eliminate the need to
    take notes on a worksheet before recording;
    bedside terminals permit the nurse to check
    an order immediately before administering
    a treatment or medication;
    planning and documentation made easy
    (writing or voice-recognition);

    computeriz
    ed

    documentatio
    n

    pros of EHRs
    information is legible;
    system incorporates and
    reinforces standards of care; and
    standard terminology improves
    communication.

    computeriz
    ed

    documentatio
    n

    cons of EHRs
    clients privacy may be infringed
    on if security measures are not
    used;
    breakdowns make information
    temporarily unavailable;
    system is expensive; and
    extended training periods may be
    required when a new or updated
    system is installed.

    21st century
    challenge in
    the nursing
    service

    Documentation
    Nursing audit
    Global nurse

    evaluation
    of care

    audit
    (n.) the examination or review of
    records;
    retrospective or concurrent

    evaluation
    of care

    retrospective audit (relating to past


    events)
    (n.) evaluation of a clients record
    after discharge from an agency

    evaluation
    of care

    concurrent audit
    (n.) evaluation of a clients health care
    while the client is still receiving care
    from the agency.

    evaluation
    of care

    tools: interviewing, direct observation


    of nursing care, and review of clinical
    records
    goal: to determine whether specific
    evaluative criteria have been met.

    evaluation
    of care

    peer review
    (n.) a type of evaluation of care
    wherein co-workers appraise the
    quality of care or practice performed
    by other equally qualified nurses;
    types: individual peer review, nursing
    audit

    evaluation
    of care

    individual peer review


    (n.) focuses on the performance of an
    individual nurse.
    nursing audit
    (n.) focuses on evaluating nursing
    care through the review of records.

    evaluation
    of care

    success is based on: accurate


    documentation

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