AUTONOMY OF THE VOLUNTEER
Autonomy is the freedom to decide and act. Autonomy consistent with the scope of professional nursing practice maximizes the effectiveness of the nurse (Hicks, 2003) [Potter & Perry’s fundamentals of nursing – Crisp &Taylor (2005)]. The client has to get enough time for the decision-making.
PATIENT CONCENT
Karla has the responsibility to get an informed consent from the volunteer to avoid the complications. The process of informed consent provides subjects with complete information regarding the study’s risk, benefits and costs. The research subjects must give full and complete information regarding purpose of the study, procedures, data collection, potential harm and benefits, and alternative methods of treatment. The volunteers must capable of fully understanding the research and implications of participation. They have the power of free choice to voluntarily consent to or decline participation in the trial. Volunteers must understand how confidentiality and anonymity maintained [Potter & Perry’s fundamentals of nursing – Crisp &Taylor (2005)]. All nurses should work within the context of civil law, such as patient safety, negligent advice, patient consent, patient freedom of movement and patient freedom [Context of nursing – Dally, Speedy & Jackson (2006)]. Moreover, Karla should follow the guidelines and principle of the organizational policy.
CONCLUSION
The ANMC highlights that the key competency of a registered nurse is the value of research in contributing to developments in nursing and improved standards of care by acknowledging the importance of research in improving nursing outcomes; incorporating research findings into nursing practice; and contributing to the process of nursing research. The nurse should do an evidence-based research before performing any new clinical trial and get the approval from the ethics committee. The nurse should consider the patient autonomy or right regarding patient decision on treatment and take an informed consent prior to treatment. In addition, the nurse should practice in accordance with the laws and legislation
REFERANCE
Crisp J, Taylor C (2005) Potter &Perry’s Fundamentals of Nursing, Elsevier, NSW
Daly J, Speedy S, Jackson D (2004) Context of Nursing, Elsevier, NSW
Lewis S N, Heitkmper M M, Dirksen S R (2000) Medical Surgical Nursing, Mosby, USA
Savage P (2007) Legal Issues for Nursing Students, Pearson Education, Sydney
Australian Nurses and Midwives Council (ANMC) 2008, code of professional conduct for nurses in Australia viewed on 1 may 2009,
Queensland Nursing council (QNC) 2005, Scope of nursing practice framework for nurses and midwives, viewed on 1 may 2009
www.qnc.qld.gov.au/upload/pdfs/qnc_policies/Scope_of_practice_framework_for_nurses_and_midwives.pdf
CASE STUDY 2
INTRODUCTION
The hospital management have identified that the staff are only partially filling the admission and discharge documentation. The issue has been discussed in the staff meetings for past two months. According to staff, they are too busy to document completely as documentation of the key components itself takes long enough. The management had initiated some education for the staff to promote compliance with the documentation policies.
Three months later, a client who had negative outcomes two weeks ago sent a complaint to the health commissioner. The hospital retrieved the records and found incomplete. These papers discuss the above case in relation to professional communication, documentation and care what might an investigator of the complaint about this matter use to access and judge situation.
PROFESSIONAL COMMUNICATION
Every interaction that we have with another person at work is a communication. Even if we never speak, our body language portrays whether we are interested or disengaged, caring or aloof. More than anything, we communicate what we think of ourselves. If we feel like a skilled expert who can compassionately deliver excellent patient care []. A public expectation is that nurses are effective communicators embedded into competency standards of nurses, [A.N.M.C. 2008] and professional code of ethics and conduct [A.N.M.C. 2008]. As Crisp & Taylor states, poor communication is a threat to nurses’ credibility and professionalism. The quality of the patient’s care relies on the health team member’s ability to communicate with another, inadequate communication results in poor client outcome; the quality of the patient’s care relies on the health team member’s ability to communicate with another. Communication is exchanging information so that each person clearly understands the other. If you do not understand each other, if you have not conveyed meaning, no communication has occurred. Savage P says professional communication is the key to consent. Queensland government says that a good clinical record provide for effective communication between health care workers. Therefore, it is so important to get the proper documentation of the client records. The investigator will look at these, analyze, and judge the situation.
DOCUMENTATION
According to Crisp & Taylor, documentation is, anything written or printed used to furnish evidence or information that is legal or official. If a nurse does become involved in any form of judicial hearing, there is no doubt that good quality documentation will help the nurse to defend the case. There have been cases in which the nursing records were so complete that the nurse accounts of the facts in dispute were accepted in preference to anyone else’s account. When the nurse record was poor, however, the nurse accounts of the facts in dispute have often been discredited to the detainments of the nurse.
Documentation is the basis for communication between health professionals that informs of the care provided, the treatment and care planned and the outcome of that care as a continuous and contemporaneous record [ ]. Nurses and midwives are required to make and keep records of their professional practice in accordance with standards of practice of their profession and organizational policy and procedure. The Professional Documentation Standards (2005), narrates that Quality professional documentation is the cornerstone of effective communication. There are seven key standards for quality professional documentation’. It must be Focused on the client, Accurate, Complete, Timely, Understandable, Always objective, Legible. Records should be more comprehensive, in-depth and frequent if the client is very ill or exposed to high risk.
The admission form comprises of the baseline information regarding the patient, past medical and surgical history, history of allergy, next of kin and their contact details, the very important reason why we are collecting this information is to avoid any complications and no other healthcare provider has to ask all these things every time.
According to legal aspects of documenting patient care by Scott. R. W, discharge planning for the hospitalized patient is a multidisciplinary coordinated process that requires careful documentation. Nurse must carefully document in the patient’s care record about the patient’s status at the time of discharge.
Crisp & Taylor (2005) narrates, when a patient got admitted into the hospital, accurate and complete documentation of the admission document is important. Ideally, discharge planning begins at the admission. Nurse revises the plans as the client condition varies. When a client discharged from the institution, a discharge summary is prepared and given to client/family, GP, home healthcare, rehabilitation/long-term care agency. It referred as professional misconduct if a nurse failed to keep record as required, inappropriate destruction and documentation and falsification of the document (Professional Documentation Standards 2005). The investigator may ask for a verity of documents which include, the admission record, patient charts, progress notes and nurses note, medication charts etc and looks at all these matters and finalizes the report about the case. The investigator may exclude the minor errors and omissions in the documentation if not related to the complaint otherwise he will take that as a serious issue and conclude the report.
Apart from all these, the investigator may question anyone in the hospital for getting the accurate data. The nurses who cared for the patient and the patient and his relatives may be crosschecked by personnel interview for the verification. The investigator will check the duty roster and the work load record for confirming, what the nurses had told is correct or not regarding their busy schedule in documenting. Audit is a part of quality improvement. It involves staff, patients, their relatives, and the healthcare team. Nursing audit is the process of collecting information from nursing reports and other documented evidence about patient care and assessing the quality of care by the use of quality assurance programs.[ "." A Dictionary of Nursing. Oxford University Press. 2008.Encyclopedia.com. 22 May. 2009 <>]
CONCLUSION
Proper documentation helps in ensuring good quality patient care. The investigator looks at the negative outcomes and the evidences that are available. The investigator uses the triangular method ie documentation, observation & interview to assess the situation. The investigator checks all the entries whether it is legible or not. In this way, the investigator assesses and judges the situation.
REFERANCE
A Dictionary of Nursing.( 2008.) Oxford University Press. Encyclopedia.com. cited on 19 May. 2009
Crisp J, Taylor C (2005) Potter &Perry’s Fundamentals of Nursing, Elsevier, NSW
Savage P (2007) Legal Issues for Nursing Students, Pearson Education, Sydney
Scott R W (2000) Legal Aspects of Documenting Patient Care, London
Queensland Nursing Council(QNC) 2005, Professional Documentation Standards viewed on 16 may 2009
www.qnc.qld.gov.au/upload/pdfs/information...of..._/Framework_information_sheet_03_Professional_documentation_standards
Bartholomew, K 2008,
Nurses Board South Australia (NBSA) 2005, Guidelines for Documentation viewed on 13 may 2009
University of Southern Queensland (USQ), Professional Communication Week 2, viewed on 14 may 2009
