Nursing Documentation: Frameworks and Challenges in Medical Records and Social Services
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- Category: Vol. 80, December 2012
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Nursing Documentation: Frameworks and Challenges in Medical Records and Social Services
Abstract
Background: Quality nursing documentation is crucial for effective healthcare delivery, yet gaps persist despite various frameworks like SOAPIE. Challenges include the need for comprehensive, problem-oriented approaches that address the complexities of modern patient care. Aim: This study aims to explore nursing documentation methods and identify frameworks that enhance clinical rea-soning and documentation quality, addressing gaps in existing practices. Methods: A literature review was conducted using databas-es such as CINAHL and MEDLINE, focusing on documenta-tion techniques, challenges, and legal implications. The review covered various documentation frameworks, including SOA-PIE, VIPS, and focus charting, and analyzed their effectiveness in acute and social service settings. Results: The review found that traditional frameworks often fall short in high-demand clinical environments. Newer methods like focus charting and the VIPS model offer improved clarity and organization. These frameworks support better pa-tient care, enhance communication, and meet legal standards. Conclusion: Improving nursing documentation requires adopting evidence-based frameworks that align with contem-porary healthcare needs. Effective documentation enhances pa-tient care, supports legal compliance, and improves operational efficiency. The integration of advanced documentation methods can address current challenges and contribute to better health-care outcomes.