Importance Of Documentation For Proper Nursing Practices

The Significance of Documentation in Nursing

What are the Importance of Documentation for Proper Nursing Practices.

Documentation is one of the most important aspects of proper nursing practices that should be developed by every nurse as an important skill. This mainly helps the nurse to keep records of every step that she had followed and each of the interventions he had taken (Srinivasulu, Namburi & Samhita, 2016). Often documentation may be done in terms of simple paper accumulated in files or can be documented in technological portal .however in most hospitals nurses are usually found to be working mostly with documentation on paper and needs to handle them over to their colleague who would be taking the charge of the paper for continuance of the care. However, this aspect of nursing is associated with different types of fraudulence and therefore a nurse needs to be very careful about maintaining the information of the documents and be careful so that this document is not mishandled or advantages are taken of it (Dolan & Farmer, 2016). The essay will mainly contain a mysterious case that had put a nurse in to a tricky situation and how she can take steps to make her free from any ethical or legal complication.

In this case scenario, the nurse had provided documentation where she had put on all the important information about all the interventions that she had undertaken taking along with jotting the important dates, medications, injections and others, moreover she had kept all the information totally confidential so that she does not get involved in any legal obligations. However, there had been incidences that had taken place in the next shift which is not mentioned in the case that had resulted in the condition of the patient getting deteriorated. When the nurse had taken a close notice of the documents she had found that her documents had been tampered with.

It is evident that the nurses to whom the nurse has delegated the work at the end of the shift was not skilled enough to handle the patient effectively. Therefore the interventions that the later nurse had taken must have had negative impacts for which the patient had developed critical situations. It is extremely important for a nurse to follow a procedural way of explanation while she is shifting the care of the patient to the nurse of the nest shift. There should be complete exchange of information that should have taken place between the two nurse regarding different aspects of the situation. It is extremely important for her dispose all her assumptions and also to block all other assumptions (New, 2014). Both the nurse should have focused on the safety of the patient clearly discussing the patient history, allergies or code status and others. Proper addressing of the past medical history of the patient is important to discuss along with the various discussion of the physical assessment. Discussions related to medication as we;; as pain management strategies applied are also needed to be considered. Discussion on the relevant social issues as well as the discharge planning is also done ("Registered-nurse-standards-for-practice-", 2017). All these steps were suspected to be not done in the proper fashion which might have confused the nurses of the later shifts. Moreover it can also be expected that the nurses of the later stages had not conducted a proper review of the documentation that had been done by the previous nurse and had provided an intervention which was brought adverse effects to the patient. The nurses in order to save themselves from legal obligations, the later nurse have trampled the original notes so that the entire blame game takes place on the previous nurse.

Types of Documentation in Nursing

On critical analysis of the situation it can be seen that the previous nurse had maintained the standard one of the practice as she had maintained the accurate as well as the comprehensive and timely documentation of the assessments along with proper decision making, actions and evaluation which the later nurse had not performed.  The nurse should immediately complain about this unprofessionalism so as to inform the higher authorities that this kind of activity will harm the organisation’s missions and goals (Sattler, 2017). She should immediately take steps to inform the higher officials that the later nurse had also not adhered to the standard two called the engagement in therapeutic and professional relationship because she had completely breached the guideline of following proper delegation methods and have not gone through proper supervision, consultation or even coordination and referrals and therefore she failed to maintain a proper professionalism. She should immediately call for the nurse who was in charge of the patient and discuss entirely about the situation. She should immediately take the patients’ vital signs and take immediate action if she find the patients condition deteriorating (Mohammeed, 2014). Once the condition of the patient comes under control, she should called for the nurse who had taken care of the patients and make her understand the standards 4 of the guidelines of comprehensively conducting assessments which states that she should work in partnership with others to determine different factors that usually affects the health as well as the well being of the patient. This would help the later nurse to take actions as well provide referrals (Gordon, 2014). Moreover the nurse should also complain about the later nurse as she had also breached the rule of standard six where she had not conducted the delegated work appropriately according to the scope of clinical or non clinical practice.

However the previous nurse is also found to have not followed the guidelines properly as well as she had not maintained the standard 6 rule of providing the clear effective timely direction as well as supervision in order to ensure that the delegated practice is safe and correct. Therefore she should also take an active step and reflect upon her own self so that she can learn from her mistake (Nakanushi & Miyanmoto, 2015) If she would have performed her duty well, the other nurse would not have taken such a wrong and dishonest step in her duty hours (Geurden et al., 2014). Both the nurses should develop properly implement the guidelines  of the standard 7 in their practice where they would determines, documents as well as communicates with different further communities, outcomes as well as goals to make the patient well.

Importance of Proper Shifting of Patient Care

According to the codes of professional conduct by NMBA, when an aspect of care is made to be delegated, it is the duty of the nurses to ensure that the shifting of care from one nurse to another does not compromise the safety as well as the quality of the care of people. As the conduct 2 statements by NMBA clearly states that any action of any healthcare professionals under any circumstantial preferences compromise with the professional standards as well as any unethical or lawful practice should be immediately reported to the upper authority. Conduct 3 of the professional conducts would be extremely important for the former nurse in order to decide what kind of immediate activity would help her. It had clearly stated that if a nurse has understood that her colleague as well as her co-workers is engaged into unlawful conduct, be in any domain like clinical, management, research or responsibility, it would be her responsibility as well as her obligation to report such conduct to the governing authority (New-Code-of-Professional-Conduct-for-Nurse", 2017). It would also be her duty to take any appropriate action which she thinks would be necessary to safeguard patient and also public interest (Saranto et al., 2016). This law has also stated that if their authority had failed to take an action, she can also go to external authority to look over the matter.

From the entire case scenario, one cannot entirely make the later nurse responsible for the critical condition of the patient as the former nurse might not have followed the entire important guidelines to follow while documenting. It might have happened that although he had put all the important information of her assessment in a proper order with every details, she might have left blank spaces in her document which had resulted the later nurse to trample with it in order to save herself from an incorrect intervention that she have had done involuntarily.

In conclusion, we can get a scenario that the former nurse had not conducted her duty responsibly while leaving her shift that had the later nurse of the shift to be in a state which was difficult for the nurse to assess. It was the duty of both the nurse to discuss the handover documents and conduct their practices. It was also the duty of the later nurse to verify the important interventions that she needs to proceed with. However it was not done and therefore the interventions that she had taken had negative impacts on the patients. To save herself from legal obligations, she had manipulated the data of the previous nurse in order to save herself and put the blame on the previous nurse. It is therefore important for the first nurse to at first conduct vital sign analysis and important diagnostic measure to assure that the patient’s condition id stable or not. After complete recovery of the patient from his unstable condition, the nurse should then inform the higher authority about the misconduct her colleague had conducted. After lodging the complaint she should have a detailed discussion with the fellow worker and both of them should recollect their guidelines set by NMBA so that no such occurrences can lead them to any legal complications.

References:

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Mohamed, S. B. (2014). Legal issues in mandatory drug testing under Malaysia’s drug intervention programme. Journal of Substance Use, 19(5), 378-381.

Nakanishi, M., & Miyamoto, Y. (2015). Documentation of nursing home residents' preferences regarding end-of-life care in Japan: Does the documentation serve as an advanced directive in care planning?. European Journal for Person Centered Healthcare, 3(3), 309-317.

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Saranto, K., Saba, V., Dykes, P., Kinnunen, U. M., & Mykkänen, M. (2016). Milestones and Experiences of Standardized Documentation. Studies in health technology and informatics, 225, 748.

Sattler, D. M. (2017). Health Law, Data Privacy and Security, Fraud, and Abuse. Health Information Management: Principles and Organization for Health Information Services.

Srinivasulu, K., Namburi, V. T., & Samhitha, A. B. (2016). Study on Documentation of Medical Records. Medico-Legal Update, 16(1).