Legal and Professional Issues in Nursing Documentation

This essay discusses the legal and professional issues that arise in nursing documentation and their correlation with national competency systems for effective nursing performance.

Running head: ESSAY
Assessment 3
Name of the Student
Name of the University
Author Note

1ESSAY
Introduction- The authority for nursing profession is primarily dependent on a social
contract that defines professional roles and accountabilities, in addition to contrivances for
public responsibility (Chin et al., 2019). In almost all nations, the profession of nursing is
well-defined and overseen by regulation, and the actions undertaken by the nurses are
controlled at the state or national level. According to Smolowitz et al. (2015) registered
nurses have typically been found to work in outpatient facilities or hospitals, where they are
entitled with the duty of delivering hands-on care to all patients, which generally
encompasses the administration of medications, management of intravenous lines, monitoring
and observing the patients' conditions, retaining medical records, and effectively
communicating with the doctors. Any kind of delay or misinterpretation of the early signs of
patient deterioration commonly result in care delay and subsequently bring about negative
health outcomes amid the patients. The case study to be analysed in this essay involves the
admission of a six month old infant in the emergency department of a rural hospital, where
two nursing professionals were involved in the care giving process. Upon arrival, although
the initial clinical diagnosis suggested the presence of gastroenteritis, later on it was detected
that the child suffered from bowel obstruction. During transfer to a tertiary hospital by an
ambulance, the infant died. This essay will elaborate on the legal and professional issues that
emerged in the case study, and will also correlate them with national competency systems for
effective nursing performance.
Discussion- Nursing documentation is an umbrella term that generally comprises of
maintaining an accurate and comprehensive record of nursing care, which has been planned
and implemented on particular patients, by qualified nursing professionals, and/or
allied caregivers, who remain under the direct supervision of an experienced or competent
nurse. Nursing documentation generally encompass clinical information, in relation to the
steps that are followed during conduction of nursing process (Lavin, Harper & Barr, 2015).

2ESSAY
Documentation has also been identified as a chief source of clinical information that
facilitates meeting the professional and legal requirements of nursing practice, and forms a
noteworthy component in care delivery. Time and again it has been established that
undertaking high quality nursing documentation is imperative in delivery of services that
meet the need and health requirements of patients, by facilitating enhanced communication
between multidisciplinary team members. This in turn ensures delivery of safe services, and
also helps in ensuring presence of continuity of care (Nguyen et al., 2017). According to
research evidences, nursing documentation typically comprises of recording information and
vital facts about a patient's background and medical history that is commonly referred to as
admission form. In addition, the process also comprises of abundant assessment forms, care
plan and taking advancement notes (Charalambous & Goldberg, 2016). Hence, the
aforementioned documents assist the nurses in recording data of a patient that are generally
captured during important stages of the care giving process.
The primary significance of nursing documentation in any clinical scenario can be
accredited to the fact that the process helps in maintaining a written record about treatment,
history, response and care of the patient, while he/she is under the supervision of a healthcare
provider. In addition, documentation also acts in the form of a succinct and comprehensive
guideline for care cost reimbursement. In the words of Stewart, Doody, Bailey and Moran
(2017) the presence of an accurate document also acts as a major evidence of care or legal
record in courts that can be used as a confirmation of the treatments and events. Furthermore,
accurate patient documentation also provides vital data for quality assurance and also reveals
the progress and advancement of patients towards expected health outcomes.
An analysis of the case scenario suggests that there was failure on the part of the
nursing professionals in accurately documenting the signs and symptoms of the patient, and
the previous medical history that eventually resulted in patient deterioration. This is a matter

3ESSAY
of major legal concern owing to the fact that the Australian Commission on Safety and
Quality in Healthcare makes it mandatory for all professionals to accurately recognise and
respond to clinical deterioration in the patient. The rule makes it mandatory for the
professionals to guarantee that patients who demonstrate deterioration in their health status,
are provided with timely and appropriate care, which in turn has been identified as a major
quality and safety challenge (ACSQH, 2018). Furthermore, the legal issue can also be
accredited to the fact that professionals should ensure delivery of comprehensive care to all
patients, regardless of their locality. This legal aspect related to patient documentation had
been formulated in 2010 in the National Consensus Statement that was sanctioned by health
ministers as a nation-wide method for response and recognition systems in acute care
facilities (ACSQH, 2010).
It was found that when a medical staff accurately identified the presence of bowel
obstruction, the nurses decided to transfer the infant to a tertiary hospital. It is imperative for
nursing professionals to document and monitor abnormal physiological observations of
patients, while specifying the actions that need to be undertaken, in order to respond to
deterioration of the health status from the normal state (NMC, 2017). However, the two
nurses failed to design the observation and response chart according to the principles of
human factor, and also demonstrated lack of competency in recording the core physiological
parameters of the infant, as mentioned in Element 1.6 of the National Consensus
Statement (oxygen saturation, respiratory rate, heart rate, temperature, blood pressure, and
level of consciousness), which brought about patient deterioration (ACSQH, 2010).
Furthermore, it has also been found that under circumstances that involve severe deterioration
in health status of patients, it is imperative for healthcare professionals to confirm that they
have adequate capability for obtaining suitable emergency support or guidance, prior to the

4ESSAY
incidence of any serious or adverse health events that might also result in death of the patients
(Christofidis, Hill, Horswill & Watson, 2016).
Under most circumstances, such rapid response system are found to generally
comprise of a range of models such as, critical care outreach, medical emergency teams
(METs), and intensive care liaison. However, it was found that the nurses working in the
rural hospital were not able to initiate any rapid response system an also did not consider the
risk of the situation beforehand (Theilen, Fraser, Jones, Leonard & Simpson, 2017). This is a
major legal concern since standards 3.1 and 3.5 make it imperative for ensuring that timely
and specialised care is delivered to deteriorating patients, and that there must be access to at
least one particular clinician, either in close proximity or on-site (ACSQH, 2010). However,
none of the aforementioned standards were followed by the two nurses in this case scenario.
Another significant legal concern can be accredited to the fact that the two nursing
professionals did not show adherence to the Australian Charter of Healthcare Rights that
allows families, consumers, patients, carers and services that are providing healthcare to
develop a sound understanding of the human rights that the patients are entitled to. The three
basic principles formulated in this charter place an emphasis on (i) ensuring equal right to all
patients for accessing healthcare service, (ii) recognises the need of providing highest quality
health services, and (iii) respects and acknowledges differences between the patients
(ACSQH, 2018). However, on analysing the case scenario it was found that the two nurses
were not able to meet the right of the patient and family members of being informed about
the treatment, services, and options in a concise and clear manner. Furthermore, they also
failed to meet the standard of delivering high quality and safe care.
The Australian Health Ethics Committee (AHEC) is also entitled with the
responsibility of delivering advice and guidance on major ethical concerns related to human

5ESSAY
health (Nhmrc.gov.au, 2019). The Code of Ethics for Nurses in Australia has also been
formulated for nursing professionals, and provides a complete outline on the professional
commitment of nurses to respect, protect, promote and uphold the basic rights of the care
seekers. It is imperative for nursing staff to value the access of patients to high quality
healthcare services (value statement 4) (NMBA, 2005). In addition, the statement also
requires all nurses to value the accessibility, availability, safety and quality of health and
nursing services. Time and again it has been found that hospice facilities located in remote
and rural regions often face challenges and barriers that typically encompass shortage of
workforce, retention and recruitment programs, restricted access to amenities, and
reimbursement issues (Humphreys, Wakerman, Pashen & Buykx, 2017). Hence, it was
essential for the two nurses to immediately recognise if adequate provisions were present in
their organisation for treating the presenting complaints manifested by the child. The value
statement 7 in code of ethics also require nursing professionals to accurately manage patient
information (NMBA, 2005). The statement also elaborates on the fact that health
documentation act in the form of records that cannot be altered or changed, other than
addition of new information about the patient. However, it was found that the nurses failed in
appropriately documenting the patient record, which acted as a significant trigger for the
health deterioration and eventual death.
The ethical principle of autonomy was pertinent to the case scenario. A strong and
specific approval had been confirmed by the Australian High Court, for Gillick decision in
relation to "Marion's Case", Secretary of the Department of Health and Community Services
v JWB and SMB (1992) 175 CLR 189. Furthermore, the concept of Gillick competence has
also been formulated as an essential component of Australian case law (Zimmermann, 2019).
Autonomy forms a crucial aspect of healthcare since it allows decision making, without the
influence of the providers. Hence, the nurses must have taken permission from the parents of

6ESSAY
the infants, prior to the transfer to the tertiary hospital. Another major issue developed in this
case was related to the concept of justice that can be defined as the ethical obligation of
professionals to perform on the foundation of fair decision between opposing claims
(McDermott-Levy, Leffers & Mayaka, 2018). Thus, the principle of justice is associated with
entitlement, fairness and equality. However, it was found that the two nurses were negligent
in providing care to the infant and also did not pay sufficient attention in diagnosing the
child, which contributed to delay in correct treatment. Further legal issues can be associated
with the fact that the guiding principles for documentation require the documents to be timely
(*1), coexistent record of care (*2), having relevant and meaningful information (*6), and
contain details about critical incidents (*9) (NBSA, 2006). Nonetheless, it was found that
adequate skills, judgment and knowledge were not demonstrated by the nurses that impaired
their clinical reasoning capability and worsened patient outcome.
The registered nurses are also entitled with the responsibility of showing compliance
with legislation, guidelines, policies, common law, and additional standards, pertinent to the
scope of practice during decision making (1.4). Further standards require them to provide
assistance and direct the individuals to resources that helps in optimising health outcomes
(2.4). Considering and responding in a timely method (3.1), documenting, evaluating and
modifying treatment plans (5.3), and monitoring the progress of patients towards anticipated
health outcomes (7.1) are some other standards of practice that the registered nurses must
adhere to (NMBA, 2016). However, there was considerable failure in their part of the nurses
in showing adherence to the standards.
Furthermore, the Australian Medical Association Council of General Practice
(AMACGP) elaborates on the fact that it is a wrong procedure to accredit nurses to
independently conduct diagnosis of patients, followed by prescribing them particular
treatment modalities, and/or referring them to other healthcare organisations. It has been

7ESSAY
proposed that independent nursing professionals should not and cannot substitute the care and
expertise provided (Parliament of Australia, 2007). This can be accredited to the fact that
conferring nurses with the aforementioned responsibilities would lead to inferior health
outcomes. Furthermore, the government also elucidates that nurses are expected to assist and
complement the work of general healthcare practitioners, and should not be considered as a
substitute for the former. However, in the case scenario, the two nurses were held
accountable for misdiagnosis of the infant, and taking decisions related to referral of the
infant to the tertiary hospital. Hence, there was a major political issue as well.
Discovery of strategies and methods to effectively deal with moral encounters in
nursing, is imperative not only for the distressed nursing professionals, but also for the
healthcare organizations that are continuously striving to advance and recover patient health
outcomes. This can be accreted to the fact that emergence of legal and ethical issues create an
adverse impact on patient care, and are related with job turnover and employee burnout. It is
imperative for the nursing professionals to demonstrate adequate familiarity with the code of
practice, and implement them on a day-to-day basis. Efforts must also be taken by the
healthcare organisations to incorporate nursing behaviour that is constant and in alignment
with the code of ethics, while defining the roles and responsibilities of the nursing profession,
and during twelve-monthly performance reviews. Moreover, particular specialty nursing
organizations, regardless of their location (rural or urban) must also formulate and enforce
position statements correlated to ethical concerns that will act in the form of a guide for the
nursing staff (Bosse et al., 2017). Like other disciplines of health and social care, the domain
of ethics and law must also be learned. Therefore, the organisations must create adequate
provision for including ethics content and legislation at the time of employee orientation, and
implementation of educational programs, with detailed examples of application of the
principles to existing issues.

8ESSAY
Presence of a practice environment that is able to provide necessary support to the
nurses, while raising moral questions and authorising them to talk about their concerns will
also act imperative in such instances (Swiger et al., 2017). A sense of collaboration needs to
be fostered among clinicians and nursing staff, in order to accurately identify the patient
priorities that require immediate attention. Furthermore, the organisations must also have the
provision for on-site nurse legal counsellors and ethicists who can initiate confidential
conversations with the staff, and help them in gaining a sound understanding of complicated
clinical scenarios from the perspective of the patients and their family members. Professional
associations will also provide necessary resources for assisting nurses with handling and
training of legal and ethical issues.
Conclusion- To conclude, the capability of nurses to accurately and quickly detect
signs and symptoms of clinical deterioration in patients forms an essential aspect of nursing
skills, in order to deliver high quality and safe care services. Under circumstances when the
nursing professionals fail to make the patient documentation complete, timely, accessible,
accurate, readable, legible, and standardized, the condition is found to significantly interfere
with the capability of the care givers who are not involved in the procedure, or are less
familiar with the patient who is currently being cared for. Nursing documentation is
habitually used by healthcare professionals who are not unswervingly involved in providing
care services to the patients. In addition, it has also been found that conducting an analysis
and evaluation of documentation data is imperative to attain objectives of evidence based
nursing. Ethical choices, both major and minor, challenge he healthcare professionals on a
regular basis, while delivering healthcare services to individuals in a pluralistic and multi-
ethnic society. Hence, the major issues related to the case scenario involved failure in nursing
documentation, delivery of care services, patient deterioration, and lack of communication.

9ESSAY
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