In the clinical setting, interprofessional teams effectively utilize data in creating knowledge that supports a culture of safe practice. One example of effective use of data in a nursing organization is proper documentation for the inter-professional team in decision making. Adequate documentation is characterized by clear, accurate, and accessible data input to enhance quality, safe, and evidence-based practice. It is done either electronically or on paper. Research shows that nurses across all the position levels are responsible for the high-quality health records documentation used across the organization (Selvi, 2017. It is critical for effective communication with each other, including other disciplines in healthcare delivery. Documentation also helps communicate the nursing contributions to the patient outcomes and the effectiveness of organizations that support quality care. This paper discusses the use of proper documentation of the medical health information by the interprofessional team in decision making.
Proper documentation is used to enhance communication within the inter-professional healthcare team for informed decision making. High-quality medical documentation improves communication effectiveness between the teams in all healthcare facilit ies (John & Bhattacharya, 2016) . The interprofessional team shares information regarding their patients and the organizational roles in an accurate, timely, and organized manner. The written and electronic documentation provides durable and easily retrievable records to help them in making decisions. It contains information regarding the patient status and the continuity of care to aid the healthcare team in ensuring informed decisions regarding the type of care provided to the patient. Other information includes the patient assessments, the clinical problems, and the patient responses to the nursing team's provided care.
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Besides, proper documentation of the medical health records is used to help the healthcare team assess the patients' progress. At the commencement of every shift, a shift assessment is completed by the nurses. The assessment information is collected, including safety checks, clinical observations, and patients (John & Bhattacharya, 2016) . It is then documented in the relevant flow sheets for other healthcare professionals engaged in providing care. The documentation gives an overview of the patient status and helps the interprofessional teamwork through the activities recorded in order. Therefore, each ward should have customized documentation to help meet the specific needs of the patient population.
Besides, data from the documentation is used by the interprofessional team in planning care for the patients. With the information gathered from each assessment shift, the care plan is developed with the healthcare team and patient's collaboration to ensure clear expectations of care (Ziebarth & Solari-Twadell, 2020). There is a timeline view of the care plan, the ongoing assessments, the diagnostic tests, and the patient's medication appointments. The information documented may also include the change in clinical state, the adverse findings, and the outcomes after providing interventions to the patients. The information is available for the entire multidisciplinary team involved in delivering care. Therefore, the team can make informed decisions regarding effective care delivery for the patients to improve their well-being.
Health care documentation is also used effectively by the interprofessional care team in making decisions regarding the patients’ intervention. Documenting the treatment and the progress of the patients throughout their hospital stay and the clinic visits ensures that every member of the interprofessional healthcare team shares an understanding of the patients' condition. For example, a chart includes documentation of what has been provided to the patient, who did it, and the results. They also ensure that proper decision-making regarding the type of intervention offered to a patient is made depending on the information recorded (Tuinman et al., 2017) . They ensure that the patients do not receive the wrong treatment or the same prescription several times. Therefore the rest of the healthcare team provides quality care.
Moreover, proper documentation benefits the interprofessional healthcare team by enabling data organization in real-time for easy accessibility in the decision-making process. Electronic health records have improved the quality of care and improved performances (McCarthy et al., 2019). The method of documentation eliminates the potentially hazardous mistakes that may mislead other members of the healthcare team. It also makes it easy for the pharmacy and the nursing personnel to finish the ordering course as there is no need for clarification or request for missing information. Research shows that the healthcare team can make informed decisions due to the accuracy of the information provided through documentation (Selvi, 2017). The system also enables data keeping in various sites where the healthcare team can retrieve any need.
Research shows that proper documentation helps the interprofessional team use the ideal scientific confirmation to sustain the clinical decisions (Ziebarth & Solari-Twadell, 2020). The recognition of the best evidence in the evidence-based practice requires forming a suitable question and the evaluation of literature, which is then documented to ensure that the team makes informed verdicts. The interventions found to have the best outcomes are documented to ensure other healthcare team members can retrieve them in providing the best care to the patients. The input of patient data further improves the flow of information in the nursing practice, management, study, and the progress towards evidence-based care. The documentation, however, requires quality and accurateness through follow-up and evaluation.
Furthermore, proper documentation is used by the interprofessional team as a source of information for continuously measuring the performance outcomes against the predetermined standards of team members. The information is used to evaluate the variance from the established guidelines while measuring and improving the processes associated with patient care, which is vital in decision making (Selvi, 2017). All the nurses must know the impact of the care they offer on the outcomes experienced by the patients. It also helps in measuring sensitive nursing information for quality indicators. The data, therefore, informs the quality improvement decisions and the evaluation of the organizational effectiveness.
Conclusion
Medical health documentation is crucial in healthcare settings as it aids the interprofessional healthcare team in decision making. It reflects on the various aspects that include the nurses' awareness level in their roles in providing quality care. Proper documentation ensures effective communication in all the members of the interprofessional health care team across all levels of the clinical facilities. Information concerning a patient is shared by all the professionals attending to them to enhance proper interventions. The records are used by the healthcare team in making an informed decision regarding the type of care to deliver as they include the patients’ status, assessments, clinical observations, and the continuity of care. Besides, it is vital in evidence-based practice, which enhances the quality of care provided. Documentation of data further helps the team make decisions regarding the patient's plan of care and assessments.
References
John, S. K., & Bhattacharya, C. (2016). Documentation guidelines based on the expectation of documentation helps accurate documentation among nurses in psychiatric settings. Asian Journal of Nursing Education and Research , 6 (2), 260-264. DOI: 10.5958/2349-2996.2016.00050.1
McCarthy, B., Fitzgerald, S., O’Shea, M., Condon, C., Hartnett‐Collins, G., Clancy, M., ... & Savage, E. (2019). Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review. Journal of nursing management , 27 (3), 491-501. https://doi.org/10.1111/jonm.12727
Selvi, S. (2017). Documentation in nursing practice. International Journal of Nursing Education , 9 (4), 121-123. DOI: 10.5958/0974-9357.2017.00108.8
Tuinman, A., de Greef, M. H., Krijnen, W. P., Paans, W., & Roodbol, P. F. (2017). Accuracy of documentation in the nursing care plan in long-term institutional care. Geriatric nursing , 38 (6), 578-583. https://doi.org/10.1016/j.gerinurse.2017.04.007
Ziebarth, D. J., & Solari-Twadell, P. A. (2020). Documentation and Storage of Records. In Faith Community Nursing (pp. 263-274). Springer, Cham. https://link.springer.com/chapter/10.1007/978-3-030-16126-2_19
