Question

Read the case study presented at the end of Chapter 5 (Guido, p. 67).

Does the failure to document an admission nursing assessment equate with the fact that this nurse did no admission nursing assessment?

What might the patient's attorney further allege in his supplemental report?

How would one decide the standard of care for this patient?

How would you decide the outcome of this case?

Answer 1

Documentation a very important record in health care sector. When it comes to health of an individual it is a must to record things right from admission to discharge. By doing admission nursing assessment the nurse comes to know about each and every details of patient and provide evidenced based care.

The patient attorney can allege as the nurse as put the patient under mefical risk by not doing assessment.

Negligence of documentation can be reported.

The standard of care is decided mostly by the nurse after the physician orders. The others without the assessment has to collect history and plan care.The care can be given upon the order of physician.

The outcome of this case should be the nurse must always document at whatever scenarios

The nurse in charge should overview the patient admission records to avoid this situation

She should find out the reason behind missing this part.