I‌‍‍‍‌‍‍‌‌‍‍‍‌‍‍‍‍‌‍‍ need a response to this discussion: Accurate and complete

I‌‍‍‍‌‍‍‌‌‍‍‍‌‍‍‍‍‌‍‍ need a response to this discussion: Accurate and complete documentation is crucial for patient safety as well as nurse safety, (Austin, 2011). Unfortunately many nurses fail to document appropriately and it has caused them losses that never had to happen if they had documented their care in a timely manner, for example at the point of care, (Austin, 2011). Because of the damage that can be done to patients and nurses, it is crucial that the importance of timely and proper documentation be addressed, fully and frequently. After reading the four elements that need to be proven to show that a nurse was negligent, I believe that proving the patient’s injury was caused by a certain standard of care breach would be the most difficult to prove, (Austin, 2011). I have recently investigated a case where a resident ended up with an in-house acquired wound. The wound nurse had done a treatment on the resident’s foot, but failed to remove the plastic protection pad, that she had used as a clean field, from under his foot. A couple of days later a charge nurse complained of a “bad” odor coming from the dressing. The wound nurse denied putting a dressing on the patient’s foot, as it was not to be dressed. Upon investigation it was noted that the plastic pad she had failed to remove, after completing his wound care, had been wrapped and taped to the resident’s foot as a “dressing” by someone else. There are currently two arguments: 1) the wound is the wound care nurses fault because she left the pad under his foot, inste‌‍‍‍‌‍‍‌‌‍‍‍‌‍‍‍‍‌‍‍ad of cleaning the area and disposing of it, and 2) the wound is the fault of the person who decided to use the plastic pad as a dressing, even though there were no orders to dress it. This question has still not been solved. I chose to review scenario 3. When it comes to outpatient surgeries it is important to make sure that the patients are stable and back to their baseline before sending them home. When a patient has complaints that are worsening, it is important to ask more questions so that a proper care decision can be made to make sure they are safe. It appeared to me that the patient’s complaints were written off. I would have not sent her home without further assessing her continued headaches and other symptoms she may have been having. A comprehensive nursing neurovascular assessment should have been done. I also would have notified the surgeon of the patient’s postoperative complaints. This would have been my first line of defense. As for the nurse who spoke with the patient after she returned home, I would have advised her to go to the emergency room for further evaluation and treatment. Finally, in each instance, I would have documented, at the point of care, all of my findings as well as what steps I took afterwards. By doing these things I would have been able to show that I did my due diligence in caring for the patient. This is what nurses must do, our due diligence and timely and proper documentation. Reference: Austin, S. (2011). Stay out of court with proper documentation. Nursing 41(4‌‍‍‍‌‍‍‌‌‍‍‍‌‍‍‍‍‌‍‍), 24-30.

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