Legal and Professional Issues in Nursing Documentation

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