Question

Did the lack of documentation in the admitting nurse's assessment and notes affect the ultimate outcome of this case?

Was there negligence on the part of the nursing staff in the care of this patient?

What could the nurse have done differently to facilitate a different outcome in this case?

How would you decide this case?

Answer 1

The documentation is very much important and crucial entity in the nursing assesment as it affects the ultimate outcome of each and every case. Documentation is the validation of the work that the event is done or not. it gives the complete information about the patient, patient history as well as therapeutic procedures used in the treatment of the patient.

Yes documentation  in the admitting nurse's assessment and notes affect the ultimate outcome of this case.

Yes it is the sign of the negligence on the part of nursing staff in the care in the indirect way as it affects the finl outcomes of the case.

Hence to facilitate a different outcome in this case there is need to make short key readings in the note pad.And utilize these findings in the future assesment.

This case can be decided on the basis of the pathological as well as dignostic reports, patient history as well as present statements of the patients familly as well as the statements of the staffs.

then the comprehensive decision should be made on the outcomes.

And the nusing staff should be advised to avoid such ill practices in the future.