Achieving Nursing Course Goals Essay

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Achieving Course Goals

After review of the topics we shall be covering, relations between my nursing practice and course material became noticeable. The course topic that I felt related most to my current practice is, "grammar and punctuation" for the following reasons. Nurses must be precise and effective when documenting which makes grammar and punctuation an essential skill to understand and perfect. The purpose of documentation is to promote effective communications, ensure quality patient care, and meet professional legal standards. Documentation is a vital component in the healthcare delivery system and is essential in communicating amongst other professionals. It is the way healthcare providers can be assure of continuity and quality care being provided to patients.

Proper documentation accommodates the need of patients and protects the nurse by providing an audit trail in a court of law. Inadequate documentation can lead to any claim in regard to a supposed act of negligence or malpractice (Curtin, 2014). Clear and precise documentation can therefore be a vital means of proof for nurses faced with a dispute over quality of care. In frequently hectic workplaces, registered nurses are faced with some constraints to accurate documentation, though, that must be overcome in order to capture the requisite clinical data (de Ruiter & Demma, 2011).

Irrespective of the nature of the working environment, nurses must accurately record all relevant facts concerning their patients' conditions (Green, 2014). In addition, documentation by nursing staff should also include all of the primary clinical concepts that relate to current and future patient care (Green, 2014). Finally, nursing documentation must provide the associated ICD-10 codes for the recorded patient conditions (Green, 2014). This final point is an especially important one because as of October 1, 2014, the ICD-10 code set replaced the former ICD-9 code set with a corresponding increase in the number of codes that are required to be learned and used routinely by nursing staff (Green, 2014).

Many times documentation errors are caused by misunderstandings or miscommunications but in some cases the sources of other documentation problems are less readily discernible. The research to date shows that in some improper documentation incidents, nurses have left blank spaces on patient's charts that have been added to by other nursing staff that caused delays in treatment and medication, while in others nurses have wrongly recorded telemetry data that resulted in delayed or even omitted physician-ordered interventions (Curtin, 2014).

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Regardless of the reason, these types of inaccurate documentations can result in disciplinary action, dismissal and malpractice lawsuits against nursing staff and their healthcare organization (Curtin, 2014).

Aside from the nursing staff, improper documentation can also be detrimental to a facility and cooperation between clinicians and allied health professionals. Facilities can lose accreditation and reimbursement opportunities from third-party payers (Green, 2014). In addition, medication errors and other medical misadventures can be caused by imprecise documentation practices (Fox & Andrus, 2011). For instance, according to Merkle and Boronow (2008), at one hospital in Maryland, "Reams of illegible handwritten paperwork resulted in functionally unusable charts which, in turn, led to increased potential for medical errors" (p. 33). In fact, more than one-quarter (26%) of all medication errors are caused by documentation errors (Wachter, 2008). Moreover, improving documentation practices is consistent with growing calls for nurses to assume greater leadership roles in their organizations and to serve as advocates for improved patient care (Murphy, 2012). As St. John and Keleher (2006) point out, "Good communication supports community nurses in their roles as a team member, client care manager and client advocate, as well as in their community capacity building activities, collaborative initiatives, submissions, and in some cases legal issues" (p. 319).

Beyond the foregoing and with this course already underway, I have set other goals which I plan to accomplish in the coming weeks. These goals include: Creating written work utilizing proper citation techniques for sources, understanding the mechanics and appropriate usage for punctuations, and mastering the editorial style of APA. I feel these goals are important to me because they reflect the success of my education and professional future and are aligned with the grammar and punctuation topic. In sum, my overall learning goals are as follows:

Develop an improved understanding of the mechanics and appropriate usage for punctuations (module #4- grammar and punctuation);

Create written work utilizing proper citation techniques for sources (module #7- plagiarism and citation:….....

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