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Copy of Nursing diagnosis vs Medical Diagnosis and Nursing Informatics
Transcript of Copy of Nursing diagnosis vs Medical Diagnosis and Nursing Informatics
While the video was humorous, false and/or incorrect nursing documentation is NO laughing matter!
Documentation is a core communication responsibility in nursing practice because it paints a clearer picture about the health and well-being of the patient while experiencing nursing care. Detailed, concise documentation helps the healthcare team collaborate to determine whether treatments are working or if modifications are needed. Documentation also proves a nurse’s accountability and gives credit to the nurse for care provided (Vogel, 2012).
As nurses, it is our duty to ensure that documentation is accessible, complete, timely, accurate, and ethical. “Documentation must reflect the nurse’s judgment, assessment, coordination of care, decisions, actions and evaluations” (Vogel, 2012).
In an article written in the British Journal of Nursing, “Record keeping is an essential part of nursing care because it details the patient’s journey through the healthcare process and can protect the accountability of staff who furnish that care”(Prideaux, 2011).
The Importance of
Correct & Accurate Documentation:
Accurate & factual nursing documentation is not optional...It is an integral part of nursing!
Nurses must not view providing accurate and quality documentation as an inconvenience but desire to provide it as a very important element of optimal patient care.
How Does False Documentation Impact Nursing?
Perhaps the biggest impact on nurses is the potential to lose your license for providing inadequate or falsified documentation; however, there are other professional and institutional implications as well.
All nurses are called to adhere to evidence based practice while implementing the standards of care set forth for us to follow. According to Anderson, nursing standards of care include the principle that any of your coworkers should be able to pick up a chart and take over the patient’s care. (Anderson, 2012)
False documentation threatens the probability of the patient receiving the best care, while accurate documentation ensures that the oncoming nurse is aware of the patient’s current state, medications, etc.
Nurses must also hold themselves accountable to ensure the documents and/or information they
co-sign is true and accurate.
Financial reimbursement has a huge impact on nursing because it determines the institution’s ability to manage their tangible and intangible resources effectively.
According to Anderson, payment from insurance companies can be denied after analyzing incorrect and/or falsified documentation. (Anderson, 2012)
Patient’s records are the first line of defense for those seeking lawsuits against nurses, doctors, and/or hospitals and it is the nurse’s responsibility to provide an accurate narrative describing the tasks of the health care team in their efforts to assist the patient.
As nursing students, we’ve heard clinical instructors repeat, “Be careful with documenting your activity. If it’s not documented correctly, you didn’t do it or you didn't do it correctly.” This is an important lesson to learn during this phase of our career, because incorrect or absent documentation may be used as information to justify a lawsuit.
Comparison of Nursing Diagnosis and Medical Diagnosis
Be a responsible nurse by providing optimal patient care and taking the time to document your activities in a clear, precise, and factual manner.
Your professional license depends on it!
One day during clinical, one of our group members went into her patient's room to perform her daily clinical duties. When the student nurse walked in, she noticed the patient's daughter was visiting him. She also noticed that the patient's sheets were soiled with blood and a faint stench exuded from the patient's bed.
Although new sheets were folded up beside the window, no one had taken the time to put them on the bed. When the nursing student asked the patient when he would like his bed bath, the daughter seemed shocked. She mentioned she was surprised because her dad mentioned earlier that he has not received a bed bath or had his linens changed in three days.
After assisting the patient with his bed bath and changing his linens, the student nurse checked the previous documentation. The primary nurses from previous shifts all documented that the patient had a bath and his linens were changed daily. The nursing student did not confront the primary nurse or tell her clinical instructor of the incident. Instead, she assisted him with a full bed bath, changed his linens, and documented her care accordingly.
What else should the student nurse have done in this situation?
A Look Behind The Walls Of False Documentation
Nursing Code of Ethics Analysis:
According to the American Nursing Association's Code of Ethics, provision 4 states, "The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care."
The primary nurses who did not provide the services they documented during previous shifts are in direct violation of provision 4.1 in which explains the primary nurse's Acceptance of accountability and responsibility to insure the patient receives optimal care.
Also, provision 3 of the American Nursing Association's Nursing Code of Ethics states, "The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient."
Unlike the primary nurse, the nursing student took it upon herself to accept the accountability and responsibility of the patient's care; however, she violated provision 3 because of her decision not to speak with the primary nurse, her clinical instructor, or the nursing supervisor regarding the inadequate patient care and false documentation of the previous staff members.
Abnormal vital signs present major risks. (2009). ED Nursing, 12(9), 100-101.
Anderson, L. (2012, 10 03). Documentation: impact on quality of care. Retrieved
Code of ethics for nurses with interpretive statements. (2010, November 15). In
American Nurse's Association: NursingWorld. Retrieved September 28, 2013, from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.pdf
Prideaux, A. (2011). Issues in nursing documentation and record-keeping
practice. British Journal of Nursing, 20(22), 1452. Retrieved from http://proxy.uscupstate.edu:2048/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=2011413974&site=ehost-live
Vogel, E. T. (2012, January). Documentation: An ethical consideration
Electronic version. SRNA Newsbulletin, 14(1), 22-23.
Summary and Conclusion:
Documenting is essential in nursing care because it is the determining factor of whether the care was completed or neglected for the patient. Nurses should document accurately and in a timely manner to avoid inconsistencies that could occur. Since documentation is important, hospitals are now having computers put in the patient’s room to document accurately and as timely as possible.
Nurses can face litigation for false documentation, and the patient’s record is the first line of defense. In a journal article on nursing care it states, nurses can be found negligent for not making appropriate reassessments and failing to detect worsening conditions in patients (“Abnormal Vitals”, 2009). When nurses falsely document they are not tracking accurately if the patient is stable or becoming worse. Failing to assess this shows the nurse is not operating as the patient advocate or providing optimal care.
In conclusion, false documentation is an ethical issue of negligence and possible malpractice where healthcare professionals can lose their license. The specific ethical dilemma of our group on falsely documenting hygienic care may not seem critical; however, what if a nurse falsely documented hygenic care and the patient had a stage four sacral pressure ulcer that was not assessed? The complications of this scenario could lead to sepsis. Falsely documenting could be a matter of life and death for the patient.
In this situation, the nursing student should have approached the nurse regarding the falsely documented bath. The student nurse should have asked the nurse if the bath was in fact given, according to what was documented, because the client and daughter stated otherwise.
By approaching the nurse, it gives her the opportunity to explain herself, clarify any possible misunderstandings, and take full responsibility. However, if the nurse disregards the issue and does not take full accountability for her actions, then it is the student nurse’s responsibility to advocate for the patient by informing his/her instructor and the unit manager.
Funny Medical Chart Bloopers - Chart Farts.
2009. YouTube. Web. 17 Sept. 2013. <http://www.youtube.com / watch ?v= Xzof5pnpcgE>.