Assignment: Installing A New Nursing Documentation System
Assignment: Installing A New Nursing Documentation System
In 400 words
Assume you are working with an implementation team in installing a new nursing documentation system for a home health agency. Historically, all of the agency’s nursing documentation was recorded in paper form. The agency has little computerization beyond basic registration information and has no IT staff.
Members of the implementation have made recommendations for installing a new nursing documentation system. Included in the list of recommendations are:
- The system needs to take into account the State Nursing Practice Act.
- The system has to include reflect state laws governing the scope of nursing practice.
- Nurses should be involved in the workflow setup for all medication tasks, including:
- drug interactions
- medication failures
- There should be visit notes template that both nurses and doctors have to approve.
- Will there be specific notes that only the nurses will approve?
- Nurses would like to determine how telephone calls are entered into the system.
Create a post, explaining fully, your answer to the questions below.
- Based on the information learned in the unit readings, would you include the nurse’s recommendations or do you have recommendations of your own? Justify your decision with supportive material.
Nurse Sarah Percy: That’s great! Are you ready to get started?
Mr Flores: Sure. Let’s go.
Nurse Sarah Percy: Let’s go into this office, it’s nice and quiet. Please have a seat.
[Sarah indicates the chair nearby]
Nurse Sarah Percy: Is the chair comfortable?
Mr Flores: Yes. Thank you.
Nurse Sarah Percy: I have to ask you some personal details and record them for our files. We keep them confidential. Is that ok with you?
Mr Flores: Yes. No problems.
Nurse Sarah Percy: Great. Are you ready to begin the assessment?
Mr Flores: Yes.
Nurse Sarah Percy: Good. Thank you. Let’s get started. Can you please tell me your full name and date of birth?
Mr Flores: David Flores, the 4th September 1952.
Nurse Sarah Percy: [Repeats details] And your address please?
Mr Flores: Flat 20/ 541 Pacific Highway, Morningside, New South Wales 2098
Nurse Sarah Percy: [Repeats details] Do you have a phone number?
Mr Flores: Yes, just a mobile. The number is 04788960123.
Nurse Sarah Percy: Do you have any allergies?
Mr Flores: I’m allergic to strawberries. They give me an itchy rash. No strawberry ice cream for me.
[Mr Flores laughs]
Nurse Sarah Percy: Oh dear that sounds nasty. So you have to stick to chocolate. That’s not so bad. [Sarah smiles at Mr Flores] That’s great information thank you. I see that you have come in today for a check-up because of joint pain?
Mr Flores: Yes, I am not as young as I once was. And I have to admit I’m a bit overweight and I’m having some pain in my joints. I play a lot of golf and like to stay active. So I thought I’d have a health check-up.
Nurse Sarah Percy: It is a good idea to have a check-up. Now you are getting older may be think about having a check-up once a year. But let’s see what we can help with today. I see that your observations have been taken and that your temperature is normal, at 36.7 Celsius. Your pulse is in the acceptable range, at 78 beats per minute, and your oxygen saturation in your blood is very good, at 98%. You mentioned that you are worried about your weight and this joint pain?
Mr Flores: That’s right.
Nurse Sarah Percy: Are you generally happy with your well-being otherwise?
Mr Flores: I’m a pretty happy person with a great family and lots of friends so my retirement from work is going great.
Nurse Sarah Percy: So you play golf? How many times a week?
Mr Flores: I love golf. It keeps me active now I’m retired. I play competition with my friends. We usually have a lunch and a few drinks after the game. I practice every day for about an hour – walking the course and hitting around. I play competition on Monday and Saturday. I’m quite good [Mr Flores smiles] and win a prize most weeks.
Nurse Sarah Percy: Wow you do play a lot. [Sarah smiles] So it keeps you in contact with your friends and you have a good time together?
Mr Flores: Yes, there is always something on at the club and I take my wife along most Fridays for the Bistro and some dancing. We do that if we aren’t minding the grandchildren.
Nurse Sarah Percy: That sounds lovely. So you live with your wife?
Mr Flores: Yes, we own our own home in Morningside. We’ve been married for 40 years now, and have two children and two grandchildren. They all come to visit us once a month and stay the night. Our place is big enough to fit them all.
Nurse Sarah Percy: What a nice way to keep the family together. Do you need help around the house at all?
Mr Flores: We have a cleaner once a week and a gardener once a week. We’ll probably down size to a retirement village in the next couple of years.
Nurse Sarah Percy: Okay, so you live with your wife in a pretty large house but have help with the chores, and the family all come to visit once a month? Have I understood that right?
Mr Flores: Yes, that’s right.
Nurse Sarah Percy: Sounds like you are pretty active and social. Are you religious? Do you attend a church?
Mr Flores: No, we don’t go to church any more. We are Catholic and go to Mass at Christmas time but that’s all. We go mostly for the grandchildren they have live animals and do the Christmas story. [Mr Flores smiles]
Nurse Sarah Percy: Christmas is a good time of year to go to church. Apart from the joint pain you are experiencing do you have any other health concerns? Do you smoke or drink?
Mr Flores: I’m a little overweight but I don’t smoke. I do have a couple of beers after I play golf and I sneak some hot chips in as well. I look forward to that.
Nurse Sarah Percy: So how may beers would you drink a day?
Mr Flores: Probably three to four
Nurse Sarah Percy: And the hot chips?
Mr Flores: Well, I might get two serves after golf if I’m hungry
Nurse Sarah Percy: Do you eat a lot of fried food?
Mr Flores: Come to think of it, we probably fry a lot of our meals: steak, fish, and chicken.
Nurse Sarah Percy: Do you eat fruit and vegetables as well?
Mr Flores: I like mashed potato and peas. I like bananas but not much other fruit.
Nurse Sarah Percy: So you have mashed potato and peas every night because you like it?
Mr Flores: Yes. I suppose its habit now.
Nurse Sarah Percy: Okay. I’ve had a look at your Body Mass Index and for your height (180 centimetres) and weight (90 kilograms), your BMI is 27.8 which means that you are overweight. At this stage you blood pressure is within the acceptable range of 135/70; however, we should probably look at a healthier diet for you to lessen your chances of heart problems or diabetes. How does that sound to you?