By Antje Sander, Stefan Schwarz
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Organisations must consider how the process of documentation forms part of overall organisational processes. Properly done, documentation can serve as a powerful problem-solving tool. ’ the many complex issues that arise in relation to nursing care. If a systematic approach is instituted, a different set of ‘stories’ begins to appear in the documentation—stories that reflect a proactive approach to health needs and nursing care, rather than a narrative of reactive responses to what has happened.
How would other unit managers see this issue? • What is preventing me dealing with this issue? • What are the consequences of not dealing with the issue? This approach allows the nurse manager to analyse the issue dispassionately and logically—thus enabling problems to be tackled more effectively. ’ questions. For example: 1. Why was this assessment not analysed? Answer: The nurse responsible became distracted and did not complete the requirements. 2. Why did the nurse become distracted? Answer: The nurse was working on a shift that was short of staff today and the nurse was trying to ﬁll too many gaps.
If the inter-relatedness of the various parts of the documentation process is continuously promoted, nurses will be encouraged to collaborate with each other in implementing a comprehensive system of professional communication. Once established, the effectiveness of the system must be continually monitored to ensure that it is producing the required standard of documentation. At first there might be some resistance to the new system among nurses. Some will be reluctant to use the system, ‘At ﬁrst there might be some resistance and some might even actively to the new system among nurses.
Anatomie fast. Der Crashkurs by Antje Sander, Stefan Schwarz