HQS 610 Topic 4 DQ 1 Discuss the value of complete and accurate documentation.

HQS 610 Topic 4 DQ 1 Discuss the value of complete and accurate documentation. – Step-by-Step Guide

The first step before starting to write the HQS 610 Topic 4 DQ 1 Discuss the value of complete and accurate documentation, it is essential to understand the requirements of the assignment. The first step is to read the assignment prompt carefully to identify the topic, the length and format requirements. You should go through the rubric provided so that you can understand what is needed to score the maximum points for each part of the assignment. 

It is also important to identify the audience of the paper and its purpose so that it can help you determine the tone and style to use throughout. You can then create a timeline to help you complete each stage of the paper, such as conducting research, writing the paper, and revising it to avoid last-minute stress before the deadline. After identifying the formatting style to be applied to the paper, such as APA, you should review its use, such as writing citations and referencing the resources used. You should also review how to format the title page and the headings in the paper.

How to Research and Prepare for HQS 610 Topic 4 DQ 1 Discuss the value of complete and accurate documentation.

The next step in preparing for your paper is to conduct research and identify the best sources to use to support your arguments. Identify the list of keywords from your topic using different combinations. The first step is to visit the university library and search through its database using the important keywords related to your topic. You can also find books, peer-reviewed articles, and credible sources for your topic from PubMed, JSTOR, ScienceDirect, SpringerLink, and Google Scholar. Ensure that you select the references that have been published in the last words and go through each to check for credibility. Ensure that you obtain the references in the required format, for example, in APA, so that you can save time when creating the final reference list. 

You can also group the references according to their themes that align with the outline of the paper. Go through each reference for its content and summarize the key concepts, arguments and findings for each source. You can write down your reflections on how each reference connects to the topic you are researching about. After the above steps, you can develop a strong thesis that is clear, concise and arguable. Next you should create a detailed outline of the paper so that it can help you to create headings and subheadings to be used in the paper. Ensure that you plan what point will go into each paragraph.

How to Write the Introduction for HQS 610 Topic 4 DQ 1 Discuss the value of complete and accurate documentation.

The introduction of the paper is the most crucial part as it helps to provide the context of your work, and will determine if the reader will be interested to read through to the end. You should start with a hook, which will help capture the reader’s attention. You should contextualize the topic by offering the reader a concise overview of the topic you are writing about so that they may understand its importance. You should state what you aim to achieve with the paper. The last part of the introduction should be your thesis statement, which provides the main argument of the paper.

How to Write the Body for HQS 610 Topic 4 DQ 1 Discuss the value of complete and accurate documentation.

The body of the paper helps you to present your arguments and evidence to support your claims. You can use headings and subheadings developed in the paper’s outline to guide you on how to organize the body. Start each paragraph with a topic sentence to help the reader know what point you will be discussing in that paragraph. Support your claims using the evidence conducted from the research, ensure that you cite each source properly using in-text citations. You should analyze the evidence presented and explain its significance and how it connects to the thesis statement. You should maintain a logical flow between each paragraph by using transition words and a flow of ideas.

How to Write the In-text Citations for HQS 610 Topic 4 DQ 1 Discuss the value of complete and accurate documentation.

In-text citations help the reader to give credit to the authors of the references they have used in their works. All ideas that have been borrowed from references, any statistics and direct quotes must be referenced properly. The name and date of publication of the paper should be included when writing an in-text citation. For example, in APA, after stating the information, you can put an in-text citation after the end of the sentence, such as (Smith, 2021). If you are quoting directly from a source, include the page number in the citation, for example (Smith, 2021, p. 15). Remember to also include a corresponding reference list at the end of your paper that provides full details of each source cited in your text. An example paragraph highlighting the use of in-text citations is as below:

The integration of technology in nursing practice has significantly transformed patient care and improved health outcomes. According to Smith (2021), the use of electronic health records (EHRs) has streamlined communication among healthcare providers, allowing for more coordinated and efficient care delivery. Furthermore, Johnson and Brown (2020) highlight that telehealth services have expanded access to care, particularly for patients in rural areas, thereby reducing barriers to treatment.

How to Write the Conclusion for HQS 610 Topic 4 DQ 1 Discuss the value of complete and accurate documentation.

When writing the conclusion of the paper, start by restarting your thesis, which helps remind the reader what your paper is about. Summarize the key points of the paper, by restating them. Discuss the implications of your findings and your arguments. End with a call to action that leaves a lasting impact on the reader or recommendations.

How to Format the Reference List for HQS 610 Topic 4 DQ 1 Discuss the value of complete and accurate documentation.

The reference helps provide the reader with the complete details of the sources you cited in the paper. The reference list should start with the title “References” on a new page. It should be aligned center and bolded, in sentence sentence care. The references should be organized in an ascending order alphabetically and each should have a hanging indent. If a source has no author, it should be alphabetized by the title of the work, ignoring any initial articles such as “A,” “An,” or “The.” If you have multiple works by the same author, list them in chronological order, starting with the earliest publication. 

Each reference entry should include specific elements depending on the type of source. For books, include the author’s last name, first initial, publication year in parentheses, the title of the book in italics, the edition (if applicable), and the publisher’s name. For journal articles, include the author’s last name, first initial, publication year in parentheses, the title of the article (not italicized), the title of the journal in italics, the volume number in italics, the issue number in parentheses (if applicable), and the page range of the article. For online sources, include the DOI (Digital Object Identifier) or the URL at the end of the reference. An example reference list is as follows:

References

Johnson, L. M., & Brown, R. T. (2020). The role of telehealth in improving patient outcomes. Journal of Nursing Care Quality, 35(2), 123-130. https://doi.org/10.1097/NCQ.0000000000000456

Smith, J. A. (2021). The impact of technology on nursing practice. Health Press.

Instructions for HQS 610 Topic 4 DQ 1 Discuss the value of complete and accurate documentation.

Discuss the value of complete and accurate documentation. Provide an example from the news or from your professional experience when documentation has proven to be the key aspect in a legal case review. What laws and policies govern proper documentation practices and who establishes these practices? Check out HQS 610 Topic 4 DQ 2.

Example 1 Approach HQS 610 Topic 4 DQ 1 Discuss the value of complete and accurate documentation.

Documentation is the process of classifying recorded data for easier retrieval, inference, and analysis. It also refers to providing documents with necessary substantiation for purposes (Quiroz et al., 2019). Healthcare professionals must document all information related to patient admission, treatment, and discharge and the receipts made available to the patient. Documentation cannot be helpful unless it is complete and accurate, and as the saying goes, “Anything not documented is not done.” Healthcare professionals must ensure that all hospital documentation protocols are followed. This discussion will examine the value of complete and accurate documentation, laws and practices governing proper documentation, and who establishes these laws and practices.

Complete and accurate documentation enables healthcare professionals to comply with law enforcement and incidence reporting because patient safety is paramount (Fondahn et al., 2016). Even though hospitals are places of safety and care, injuries and medical errors can occur, prompting litigation and fines for patients and their caregivers. Accurate documentation ensures continuity of care as it unwraps patient behaviors and their response to particular medications in different settings.

Upon the patient’s behavior being established, the caregiver can prepare a care intervention that the patient identifies with or agrees to eliminate conflicts. Complete documentation is a tool for sharing valuable knowledge in practice. Nurses analyze these documents, form diagnoses, and inform their colleagues of the findings for further consultations. Incomplete documentation would compromise this learning process, leading to medication errors and possible fatalities since patient care allows minimal or no error margins. Patient care compromise can lead to hospital-associated infections and injuries that might be fatal (CDC, n.d.).

There has been a recent case in the healthcare facility. A 71-year-old patient was brought to the facility in the emergency department. He was unconscious, and the vital signs showed bradycardia, with a heart rate of 32 and a low blood pressure of 71/49. The relatives reported that he had overdosed on morphine as they found an empty morphine bottle next to him. The patient was started on naloxone to reverse the effects of the opioids.

The patient had cancer and was on morphine for pain management. The patient failed to respond to the medication, and resuscitation efforts were unsuccessful. The patient died, and a week later, the hospital was sued for negligence. The patient’s relatives claimed that the patient stayed in the hospital for three hours before being attended to.

The care providers did not intervene or resuscitate the patient after admission. The hospital records came in handy and showed all interventions implemented, including the time and implementor, and the relatives dropped the case after gaining that understanding. Documentation saved the hospital from a hefty lawsuit and a soiled reputation. It also saved the involved care providers from unfair allegations.

Documentation practice is crucial in healthcare, and some international laws and policies govern it. Good record-keeping practice (GRP) is an internationally accepted policy in documentation practice that ensures that the information documented is reliable and verifiable and adheres to integrity values. This policy provides the effectiveness of patient care and patient safety. The laws of documentation practice dictate that documentation should be complete and accurate, such that a treatment case can be traceable from the documents in all aspects.

Good documentation practices must be attributable, legible, original, contemporaneous, accurate, and complete, as Cundell et al. (2020) explain. Several bodies establish these laws and policies. They include the International Organization for Standardization (ISO) and Good Manufacturing Practice (GMP) agencies. In addition, facility management is critical to establishing accurate and complete documentation.

Documentation practice is a critical system that must be incorporated by facility management. This incorporation is essential because any medical error can cause hefty financial loss to the facility if the nurses cannot ascertain who caused the error. Using documentation, the nurses can trace all patient treatment activities and pinpoint the cause of medical errors. Therefore, it is advisable that facilities record and document all patient activity from hospital admission to discharge. Legal cases are prosecuted on documents available; thus, one cannot have accurate legal standing unless complete and accurate documents are available as part of the case defense.

References

Cundell, T., Guilfoyle, D., Kreil, T. R., & Sawant, A. (2020). Controls to minimize disruption of the pharmaceutical supply chain during the COVID-19 pandemic. PDA Journal of Pharmaceutical Science and Technology, 74(4), 468–494. https://doi.org/10.5731/pdajpst.2020.012021

Fondahn, E., De Fer, T. M., Lane, M., & Vannucci, A. (2016). Washington Manual of patient safety and quality improvement. Lippincott Williams & Wilkins.

Centers for Disease Control and Prevention (CDC), (n.d.). Current HAI Progress Report: 2021 National and State Healthcare-Associated Infections Progress Report. Healthcare-Associated Infections (HAIs). https://www.cdc.gov/hai/data/portal/progress-report.html Quiroz, J. C., Laranjo, L., Kocaballi, A. B., Berkovsky, S., Rezazadegan, D., & Coiera, E. (2019). Challenges of developing a digital scribe to reduce clinical documentation burden. NPJ digital medicine, 2(1), 114. https://doi.org/10.1038/s41746-019-0190-1

Example 2 Approach HQS 610 Topic 4 DQ 1 Discuss the value of complete and accurate documentation.

The importance of accurate and complete documentation is a high priority in healthcare to improve patient safety and quality of care. It is the most efficient way for clinicians to communicate the patient’s story, what they were suffering with and how it was treated, which in turn helps any future clinicians or medical teams to evaluate a patient’s treatment plan (Jorgensen & Kollerup, 2022).

Proper documentation is part of continuity of care, regardless of the type of medical treatment. Accurate and timely documentation is necessary for reimbursement purposes. Missing vital information causes unnecessary delays and possibly even denial of reimbursements and benefits. Required nursing documentation has risen exponentially, with charting taking more nursing time than direct patient care.

Patient skin assessment is an important part of every admission. Our institutional policy is to have two registered nurses to assess the skin, take photographs of the wound and upload them to the electronic health record (EHR) with accurate documentation of staging of wound with measurements. Appropriate wound care measures are instituted based on findings including wound care nurse and nutrition consult.

We had incidents where patients came with deep tissue injury and ended up in stage 2 wounds, maybe due to refusing to be repositioned because of pain or fractures etc. Healthcare facilities can be sued for hospital acquired pressure injuries. According to Kaucher et al. (2022)” litigation arising from pressure ulcers and skin breakdown constitutes an increasingly large percentage of liability claims against hospitals, subacute care facilities, inpatient rehabilitation facilities, skilled nursing facilities, and assisted living facilities.”

The best way to reduce the risk of skin breakdown and related claims is to provide and document appropriate care. From a legal and risk management standpoint, documentation of each element should be accurate, timely, and complete per organizational protocol. Accurate documentation is vital for reporting daily events, planning and evaluating patient care, facilitating communication, organizing nursing practice, safeguarding professional accountability, and ensuring regulatory standards (Kaucher et al., 2022).

Regulatory agencies oversee different components of the healthcare system, from individual providers to entire hospitals. The agencies include federal, state agencies, and private regulators. The Department of health and human services (DHHS) implements most of the federal healthcare regulatory infrastructure through component agencies include Agency for Healthcare Research and Quality (AHRQ), Center for Medicare and Medicaid Services (CMS), Center for Disease Control and Prevention (CDC) are involved in patient safety and quality reporting Fondahn et al., 2016).

All of these have the objective to improve patient safety, by assisting with the measurement and description of events, the design of interventions, the reporting of measures and outcomes, or the proposal of norms. These regulatory agencies provide the foundation for improving quality of care and protecting patients by enforcing its standards and performance objectives. 

References

Fondahn, E., Lane, M., Vannucci, A., & De Fer, T.M. (2016). The Washington Manual of Patient Safety and Quality Improvement. Wolters Kluwer.

Kaucher, J., Bohnenkamp, S., Lou Kennedy-Evans, K. & Bohnenkamp, M. (2022). Legal documentation in Pressure Ulcer/Injury Cases, MEDSURG Nursing, 31 (2), 77-81.

Trainer, N. (2023). Critical Care Nurse, 43 (1), 10-11. doi: 10.4037/ccn2023527.