Discussion About Diagnoses in Charting

Discussion About Diagnoses in Charting

Diagnoses in charting provide a comprehensive overview of specific types of conditions, related comorbidities, and risk factors. It enhances specificity and accuracy, thus improving the process of diagnosing, billing, and implementing a clinical intervention. For instance, the heart and Vascular POA Diagnosis Checklist gives logical steps for evaluating chronic conditions by identifying specific risk factors, acuity, and comorbidities. The chart is grounded on the need and importance of accuracy and specificity when assessing a patient. Charting skills are essential in patients’ documentation as they help develop logical steps to manage a chronic condition (Lee et al., 2019). Applying charting skills in diagnosis helps acknowledge the essence of charting a specific type of condition and its commodities.

Improving diagnoses with the help of a preceptor has refined my understanding of nursing diagnoses and enhanced my charting skills. As a result, I am able to identify a specific problem, examine patient acuity, and develop effective care plans with minimal errors. Also, correcting diagnoses with the help of a preceptor has enhanced my understanding of the essence of charting specific types of diseases and their risk factors. Prior to learning how to correct or improve diagnoses, I used to overlook the essence of charting specific types of disease and resulting comorbidities. Still, I was unfamiliar with the influence of comorbidities on patient acuity.

Accurate diagnosis minimizes the wastage of limited resources such as time, labor, and money. It also enhances

patient safety. Charting documents critical patient details used to determine the specific type of disease and enhances care provision. Besides, effective diagnoses in charting help ensure accurate billing since medical billers rely on the data recorded in the patient’s charts. Additionally, charting indicates safe, ethical, and correct application of knowledge, critical thinking, and clinical judgement skills (Flaubert et al., 2021).

References

Flaubert, J. L., Le Menestrel, S., Williams, D. R., & Wakefield, M. K. (2021). The future of nursing 2020-2030: Charting a path to achieve health equity. DOI: 10.17226/25982

Lee, S., Jeon, M. Y., & Kim, E. O. (2019). Implementation of structured documentation and standard nursing statements: perceptions of nurses in acute care settings. CIN: Computers, Informatics, Nursing, 37(5), 266-275. DOI: 10.1097/CIN.0000000000000510