Question

What is meant by continuity of care? Why is it so important?

B. Explain how documentation is pertinent during a lawsuit. What types of errors could possibly make you, the nurse, “look bad”?

C. Explain the rights of the patient regarding his or her medical record.

D. List at least five types of occurrences for which an incident or variance report should be completed.

E. Explain the five types of documentation mistakes that carry increased risk for malpractice.

type please

Answer 1

A. Continuity of care refers to high quality and cost effective ongoing healthcare service, provided by the members of health care team to achieve long term goals. It aids in providing standardised care resulting in patient satisfaction and better care outcomes. Continuity of care saves time in terms of unnecessary investigations for deciding on management, every time the patient visits the hospital,improves the therapeutic relationship with health care team,minimises emergency admissions and involves patient actively in health care decisions.

B. Documentation in nursing serves as a channel of communication regarding the encountered client care events during particular time frames. Records maintained by nurses also contains all the necessary health care informations regarding the client, which prevents potential errors from happening during the course of hospitalization.A patient record serves as a legal document too. It can safeguard the patient as well as the nurse or the health care professional.Patient record should be accurate,up to date,comprehensible and must contain factual data. Thus a medical record serves as an important evidence in a malpractice lawsuit , as it relies more on the medical record as a legal proof than on the patient's or nurses verbalization.

Improperly recorded events (like falls,change in client's health status,treatment initiated), failure to record a client care incident etc can make the nurse vulnerable to be alleged on unfavourable care outcomes.For example not resucitating a collapsing client with DNR order, recording the series of events legibly can safeguard the nurse in case of lawsuit. On the otherhand,administering a medication without checking for recorded allergies can hold the nurse accountable too.

C. Right to keep the informations in medical record confidential

Patient's information could be released to a third party only after taking consent.

Patient's medical reports should be properly maintained and stored for further references and continuity of care.

The Health Insurance Portability and Accountability Act grants rights to the patient to access their medical records.

D. All types of unusual events in a health care scenario needs to be documented. Some examples are :

• Sentinel events like slips,falls leading to life threatening complications,accidents,fire etc that may cause injury or death,
• Near misses like identifying a potential error before it happens
• Adverse events like Medication error(drug allergies,toxicity,wrong medication administered), injuries sustained during a medical or nursing procedure
• No harm events like a fall due to negligence without causing any fracture or complications
• Abusive acts towards the patient or from the patient or relatives

E. Not mentioning the date,time and sign for an entry - may hold the person writing or entering the details accontable and makes it a complete  legal record. Also helps in periodic evaluation and modification of treatment strategies.

Incomplete documentation - creates confusion whether  care is provided or not at a particular time. Sometimes patient may receive double doses as a result and leads to complications. Blank or not applicable forms needs to be striked off or to be marked as NA.

Failure to document omitted medications or treatments - due to which patient may receive medications or procedures that are not necessary or contraindicated

Using non standardized abbreviations - creates confusion and misinterpretation. Health care professionals should use only standardized abbreviations in medical records.

Writing in illegible handwriting - creates communication errors. Unless not clarified, the nurse may misinterpret the writting and lead to wrong treatment.

Adding entries late - late entries may lead to inadequacy or loss of details due to human tendency of forgetting things. Late entries need to be specified.