Documentation Practices in Healthcare

Reading diary

Reading logs do not have an absolute word limit, but you are recommended to use roughly 150-200 words (not including the headings and other text already on the template).

All logs should use peer reviewed, published material and at least one of the logs should use a journal article.

Identify your learning objectives for this reading log? (What do you want to find out and why.)

The learning objectives of this log is as follows:

• To analyse the usefulness of the better documentation in improving care experiences of patients
• To evaluate the documentation issues that nurses face during the care delivery
• To determine and analyse the components of good documentation in the healthcare
• To evaluate the importance of the standardise documentation inro different care context

Outline your search strategy for finding suitable reading material? (e.g. what database or organisational website did you access, what search terms did you use)

Online database:

In your own words, summarize the main points of what you have read (use bullet points)?

Through preparation of this reading of I have learned the following things

• The importance of the good documentation and proper record keeping in the nursing (Kent and Morrow, 2014.)
• How the accurate and systematic record keeping improves the overall care experiences of the patients
• The sets of standard that nurses and midwives need to meet while forming good documentation (khu‐Zaheya et al. 2018)
• The essential components of the good record keeping that nurses and midwives need to consider to provide good care to patients

Describe to what extent your learning objectives have been met? (use bullet points)

Through analysing the content of the selected reading material, I am able to develop good understanding on the following:

• Under NMC (2010), good documentation is fundamental to improve the overall care outcomes of patients (Kent and Morrow, 2014)
• The NHS healthcare authority needs to emphasize on good documentation of patients’ health related record by nurses, midwives and allied health professionals (NMAHPs).
• NHS authority needs to maintain the required infrastructure and the well-constructed management system to support the good documentation and record keeping

Reference list:

Akhu‐Zaheya, L., Al‐Maaitah, R. and Bany Hani, S., 2018. Quality of nursing documentation: Paper‐based health records versus electronic‐based health records. Journal of clinical nursing, 27(3-4), pp.e578-e589.

Kent, P. and Morrow, K., 2014. Better documentation improves patient care. Nursing Standard (2014+), 29(14), p.44.

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