Question

Read the case study, then answer the questions that follow.

Susan is a supervisor in aged care services and receives information from an older person’s support worker that they have experienced several near falls. Workplace procedure says this information should be recorded in the older person’s progress notes and discussed immediately with members of the older person’s care team. Susan records the information as per the procedure. She then organises a meeting so that timely action can be taken to identify hazards that may be putting the older person at risk.

Susan follows her organisation’s policy and procedures on safe and secure storage of information and uses her personal password to access the electronic progress notes of the older person and makes an entry. She also makes notes in the hard copy care plan which is stored in a locked filing cabinet.

However, one day, Susan is in a hurry. Rather than recording the information she has received from a support worker in the care plan, she writes a note in her diary. She plans to update the progress notes at a later stage that day, but forgets.

1. Why is it important that Susan complete the documents and records accurately and with appropriate detail?

2.How has Susan ensured the older person’s records are maintained?

3.How has Susan ensured that older person’s records are stored according to organisational policy and protocols and in a timely manner?

Answer 1

1.In nursing documentation is a very important step in order to complete a care given or recording an incident that has happened .when an incident is recorded on the same day and within a short duration ,evidences supporting the incident will be available as well as if the health care team involved in the incident will be available in the place itself therefore clarification can be made at the place of incident with witness and evidence.If there is a delay in recording there are chances that the situation can be manipulated and the next day the staff or team member might not be present to record the clarification or he or she can deny the incident.As mentioned in the scenario if the incident was reported to the supervisor and she forgets to report it ,there the life of the patient is at risk as well as the intergrity of the profession will be questioned,next time an incident occures the support care taker would doubt to report it because previously no action was taken

2.In the scenario Ms Susan has ensured that the findings regarding the hazards to older patients are being recorded in hard copy and soft copy format ,she has ensured the safety of the documents by entering the data on an online platform using personal id and secured the hard copy in the locked cabinet

3.In the scenario Ms Susan has followed the organisation policy by making sure the incident of the fall hazard has been recorded in the progress note of the patient on the same day that the incident was reported to her.To avoid confusion she made sure that the details were recorded on the online copy as well as hard copy by personally accessing the files and recording by her self maintaining confidentiality of the report