What are the key factors that contribute to the improvement of nursing care documentation?

Introduction

The CPA topic is based on the enhancement of clinical documentation through the extended use of electronic health record (EHR) to effectively improve the overall patient care pattern across the clinical practice environment. The improvement in the medical documentation process not only enhances the documentation quality but also elevate the quality of health care outcomes in the clinical setting (Glen, et al., 2015). Indeed, good record keeping practice is highly needed to enhance the quality of multidisciplinary communication and clinical consultation. The improvement in the nursing care documentation is based on several factors including continuous control/monitoring, enhanced leadership style, compliance with the documentation conventions, managerial accountability, and employee participation (Vafaei, Manzari, Heydari, Froutan, & Farahani, 2018). Therefore, the clinical documentation practice will substantially enhance my awareness and knowledge of these attributes in the context of improving the quality of patient care interventions and exploring new gateways to professional development. 

The Need for Clinical Documentation

The Rationale for Topic Selection

Clinical documentation through EHR elevates the access of health care professionals to significant clinical information and assists in reducing medical errors while improving interprofessional communication and care integration between patient visits and providers. The enhancement of clinical documentation facilitates patient monitoring that eventually elevates the overall patient care experience in the medical setting (Yanamadala, Morrison, Curtin, McDonald, & Hernandez-Boussard, 2016). The enhancement of EHR-handling skills is highly needed to effectively improve patient safety, culturally-sensitive treatment, patient-nurse communication, and workflow improvement in the clinical setting (Tanner, Gans, White, Nath, & Pohl, 2015). These findings substantiate the selection of clinical documentation project in the context of improving health care outcomes.     

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