For the introduction, I would like to inform you all that according to Charalambous and Goldberg (2016), it is found that old age-old patients often suffer from memory issues due to which they forget about their medication and care plans, but timely updated documentation of their health status helps them to maintain their health. The nurses are required to follow the nursing practice standards such as comprehensive care, effective monitoring, evaluation, and documentation with well-structured and maintained handovers or medical records so that with a written record a safe and quality care can be delivered that will improve the health of the old patients. With frequent documentation, the chances of mis-intervention or deterioration can be reduced to a great extent (Moody, Phinney, and Boschma et al. 2020). With the help of the latest technology, the documentation can be maintained in an electronic manner in a fast and effective manner, so that the old patients of rural and remote areas can review their documentation and get medical care without traveling to the hospitals or centers (Moody et al. 2020). In older patients with documentation of the health outcomes, it can be ensured that whether the patient requires advance care planning or not, depending upon the health records of the patients. Documentation is found to reduce the hospital stays of the old patients as it ensures a reduction in the errors or miscommunication. This is associated with patient-centered care that results in the delivery of safe care thereby marinating the nursing professionals to ensure least or no harm to the patient and improved health outcomes (Ni Chroinin, Neto and Xiao et al. 2016).
So, the research question is
How timely and frequent documentation of older patients impacts effective communication and positive health outcomes? The PICO elements include Population (P): older patients, intervention (I): timely and frequent documentation, comparison (C): poor health, outcome (O): for effective communication, and positive health outcomes.
The methods for the literature retrieval process are:
For this research, the articles that were published in credible and reliable journals such as CINAHL, PubMed, and MEDLINE were used. The articles that were published in the English language and were only in the published range from 2015 to 2020 were selected. The use of Boolean operators was used such as AND, OR, NOT. Various keywords were also used are documentation AND older patients, documentation OR communication in older patients, and documentation OR older health. The inclusion criteria are that the articles with information about older patients, communication, documentation, and positive health results were selected. The eligibility criteria will be rechecked for each selected article and those articles that do not fulfill the criteria were excluded. Moreover, those articles that maintained the research ethics were selected.
The results that were obtained based on the literature review conduct stated that it was found that the nurses do poor handling of handovers, no face-to-face communication with the old patient, no feedback documentation, and no frequent assessment. The other issues are poor knowledge of the nurses about the documentation and acknowledgment of the old patient’s feedback. It was also found while conducting the review that due to the absence of a sufficient workforce the nurses do not spend much time with old patients and frequent documentation is not maintained. It was also found that in some cases the patient had no information about the importance of documentation for his/her better health.
Talking about discussion for this research topic, it is stated that the documentation is a very important part of nursing care in the case of old patients. This is because old patients often show different responses to different drugs or medications. Therefore, documentation of their health outcomes helps to evaluate their health status. For example, if the health condition is deteriorating then it can be documented so that the information is transferred to all the health professionals and alternative methods can be used for management. This documentation can be maintained in form of medical records or handovers, so that the risks of medication errors, miscommunication, or skipping of medication can be managed effectively (Subramaniam, Tiruvoipati, and Green et al. 2020). It is also found that old patients often forget about their medications or sessions so if the documentation is proper and timely updated then a written proof will be maintained that will help the aged patient to keep the record of his/her care plans. If there is effective documentation then the chances of gaps, overlaps, or mishaps can be prevented; such as the errors with look-alike and sound-alike drugs. This will help in resulting positive health outcomes in the case of older patients as the chances of inconsistencies and inaccuracies will be reduced (Platts-Mills, Richmond, and LeFebvre et al. 2017). Moreover, if the documentation is structured well then with effective transfer of information among health professionals there will be a patient-centered approach that will result in improved patient’s health.
In a conclusion, it is concluded that documentation can result in improved health outcomes, and better health if it is conducted timely and frequently. This documentation in older patients also contributes to effective communication. This is because proper documentation ensures the transfer of complete information among health professionals and written records for the patient’s health status. This ensures the safety and improved health of the patient.
Charalambous, L. and Goldberg, S. 2016. ‘Gaps, mishaps and overlaps’. Nursing documentation: How does it affect care?. Journal of Research in Nursing, vol. 2, no. 8, pp.638-648. https://doi.org/10.1177%2F1744987116678900
Moody, E., Phinney, A., Boschma, G. and Baumbusch, J. 2020. The contribution of documentation systems to how nurses understand older people's cognitive function in hospital. Advances in Nursing Science, vol. 43, no. 3, pp.278-289. https://doi.org/10.1097/ANS.0000000000000315
Ni Chroinin, D., Neto, H.M., Xiao, D., Sandhu, A., Brazel, C., Farnham, N., Perram, J., Roach, T.S., Sutherland, E., Day, R. and Beveridge, A. 2016. Potentially inappropriate medications (PIMs) in older hospital in‐patients: Prevalence, contribution to hospital admission and documentation of rationale for continuation. Australasian Journal on Ageing, vol. 35, no. 4, pp.262-265. https://doi.org/10.1111/ajag.12312
Platts-Mills, T.F., Richmond, N.L., LeFebvre, E.M., Mangipudi, S.A., Hollowell, A.G., Travers, D., Biese, K., Hanson, L.C. and Volandes, A.E. 2017. Availability of advance care planning documentation for older emergency department patients: A cross-sectional study. Journal of Palliative Medicine, vol. 20, no. 1, pp.74-78. https://doi.org/10.1089/jpm.2016.0243
Subramaniam, A., Tiruvoipati, R., Green, C., Srikanth, V., Hussain, F., Soh, L., Yeoh, A.C., Bailey, M. and Pilcher, D. 2020. Frailty status, timely goals of care documentation and clinical outcomes in older hospitalised medical patients. Internal Medicine Journal, vol. 2, no. 33, pp 2. https://doi.org/10.1111/imj.15032
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