What is the name of the Practice Standard or Practice Guideline?
The selected Practice Standard, “Documentation,” was developed by the College of Nurses of Ontario (CNO). Documenting patients’ records is important for complete and accurate records. It also guarantees that any provider, practitioner, or health care worker who contacts a patient has relevant information on any interventions, treatment, or outcomes.
What is the importance?
Achieving this includes documenting patient care since it provides safety, exhibits continuity in the care offered, and offers legal defence in law. Documentation leads to the effective passing of shifts, handoffs, and referrals, ensuring the patient has received the right care from the right health practitioner. They also contain record legal documentation to protect the patient and the health care practitioners in case of litigations. Documentation is central in evaluating the quality of care given; it assists in enhancing quality care (CNO, 2023). It can, therefore, be said that it is a fundamental part of nursing practice.
Reflect on a time in your clinical practice when this Practice Standard or Practice Guideline would or has been important.
I had a patient with COPD on the ward; the patient had a PRN prescription for hydromorphone when in SOB. During the shift, I gave the medication four times and wrote down every time I did it, including the patient’s oxygen saturation level, which ranged from 88%-90% while on 4L O2, via nasal prongs, and how effective it was. It also made it possible for the subsequent shift to receive information about the patient’s state and the care given to him, which was important for care continuity and assessing the effects of the offered care on the patient.
References
College of Nurses of Ontario. (2023). Code of Conduct Practice Standard. https://www.cno.org/globalassets/docs/prac/49040_coc_effective_202306.pdf
