Importance and implementation of nursing documentation.

In nursing care, one of the most important activities is the accurate documentation of processes. Nursing documentation therefore involves the recording of interventions and care as patients receive them from nurses. Documentation is a critical process because it is used as evidence on the decision-making process of physicians. This helps in the justification of their orders and shows the overall results obtained following the provided care (McCarthy et al., 2019).Importance and implementation of nursing documentation.

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According to Alkouri, AlKhatib, and Kawafhah (2016), nursing documentation is a powerful tool of communication that gives evidence concerning the work done by the nurse. It also helps in the evaluation of the journey and success of the patients. The designing and implementation of new systems for nursing documentation is a complex process. Doing this requires the presence and efforts of a nurse leader (Lunden et al., 2017).Importance and implementation of nursing documentation. This is a vital member and asset to the implementation team because the system will essentially be used by nurses. For a nice leader, to design and implement a new system may prove challenging when a nurse leader’s knowledge in nursing informatics is limited.Importance and implementation of nursing documentation.

McGonigle and Mastrian (2017) define the systems development life cycle (SDLC) as the stages of a system’s life. The SDLC involves complex steps aimed at designing new systems applicable in nursing informatics. These are important systems used in nursing documentation systems. As technology continues to evolve, organizations are also changing to using software and electronic health records for the documentation of data (Evans, 2016). Importance and implementation of nursing documentation.The process of developing new software can be complex but the role of SDLC helps to break it down to manageable sections. SDLC involves many steps including an understanding of the business need or problem, the right way of addressing the needs, developing a plan. The implementation of that plan, the evaluation of the implementation, maintenance, reviewing, and destruction as explained by McGonigle and Mastrian (2017).Importance and implementation of nursing documentation.

Requirements and planning definition

Before the commencement of the project, it is important to do a feasibility study. This helps in developing a plan and a budget for the whole process. There are various steps that can be used in doing this and one of the strategies is the technological, economic, legal, operational, and schedule (TELOS). The TELOS strategy steps are used to address the issues as well as the technological capabilities for carrying out the project. Importance and implementation of nursing documentation.It thus looks into the infrastructure and expertise necessary for completing the project, return on investment, a cost-benefit analysis, the assessment of the project’s legal ramifications, to determine the effectiveness of the way the project will meet the organization needs, assessment of the timeframe viability and the necessary resources (McGonigle & Mastrian, 2017).Importance and implementation of nursing documentation.

Analysis

This phase is used in determining the system’s requirements. It thus involves a detailed analysis of the organization’s business needs. At the same time, the business practices and workflows of the business are examined in detail. In a similar manner, options are put in place for changing the business process (McGonigle & Mastrian, 2017).Importance and implementation of nursing documentation.

Designing the new system

In the design phase, the focus is on the system’s data design, design, and interface. The function of the design team here is establishing the programs that would be needed and the way those programs would work. The interface is how system will look and feel like to the users. The essential data for this program will also be determined. This is the phase where prototypes and mockups are created. This helps in the clarification of the requirements and to ensure all the team members are on the same page for the avoidance of glitches as seen in McGonigle and Mastrian (2017). The input of the nurse leader is critical at this point.Importance and implementation of nursing documentation.

Implementation

This is where the designs, through programming codes are brought to life. Different programming languages can be used here. The choice of the right language or code depends on the application requirements (McGonigle & Mastrian, 2017).

Post-implementation support

One of the main activities in post-implementation support is testing. The process of testing the system occurs in 5 stages, including individual programming modules, volume, beta testing, integration and the whole system. Importance and implementation of nursing documentation.A majority of the programs are created as modules thereby allowing each individual module to be tested individually. After testing the individual modules, the whole system is then evaluated considering the expected data volumes and the platform. In Beta testing, the system is used by the various users to ensure everything they need is there. After all the testing, the next stage involves maintenance of the system. According to McGonigle and Mastrian (2017), system maintenance includes supporting the system users and making any necessary software changes.Importance and implementation of nursing documentation.

Nurses are therefore capable of using their experience, knowledge, as well as clinical expertise in every stage of the SDLC during the development of new systems/software. Since they are the main users of the system, they can easily identify problems within the system as well as offer suggestions for system improvement. During evaluation, the analyzing feedback from various nurses is of great significance. Analysis of such feedback helps in the creation of systems that are user friendly for the specific documentation needs of the department or facility.Importance and implementation of nursing documentation.