Health Care - Communication and documentation nursing

Running head: HEALTH CARE
HEALTH CARE
Name of the Student
Name of the university
Author’s note

HEALTH CARE
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Communication and documentation nursing
Electronic document and record keeping is a vital part of the registered nurses. The
quality and the coordination of the care of the patient depends upon the communication between
the various health care providers. Electronic documentation is a communication that is used by
the registered nurses in order to exchange information about the care of the client (Braaf, Riley
& Manias, 2015). Electronic communication is important for the registered nurses as it saves
time, prevent clinical errors and also serves as legal documentation in case of any lawsuits in the
future.
This paper will identify the missed communications that had taken place, including the
importance of the early warning tools and documentation policies and the escalation rules. The
paper will also focus on the suitable strategies that can be taken to mitigate missed opportunities
for the communication and the accountability of the RNS in the case.
Missed opportunities and gaps
Troy was presented in the emergency department with restlessness and cannot tolerate
any food. During taking the vital signs of the child, although RN Mason did not document the
capillary refill, although the capillary refill of the child was a bit brisk. RN Mason also did not
measure the blood pressure.
Another gap in documentation was noted in part of RN Avis, who entered wrong
documentation. When the RN saw development of rashes in the chest and back and recorded
them as non-blanching rashes, although in the coroner’s report he had recalled that the progress
reports had been wrong and that the rashes were blanching and maculopapular in appearance.

HEALTH CARE
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After RN Avis’s vital signs, Dr Tajvidi examined Troy, but did not check the viral signs again.
He made his assessments as per the records taken half an hour before. Dr Tajvidi has admitted
that it has been a great mistake for not taking the vital signs before the discharge. Troy could
have been investigated for the possible signs of bacterial infections and blood tests could have
been ordered. In fact, it has been reported, that Dr Tajvidi has made decision to discharge Troy
after, even after Ms Mackilin proposed to do the blood tests. Dr Tajvidi concluded that Troy
suffered from fifth disease based upon the initial presentation of high fever, but no blood tests
has been done to see any signs of infections. No blood tests for the detection of the inflammatory
markers were conducted. While Troy was being admitted in the hospital, there was a “between
the flags” form, but RN Avis had not used for electronically recording of monitoring the vital
signs for Troy.
In this case study, there had been several instances where lack of communication has
been witnessed within the health care staffs as well as between the staffs and Troy’s parents.
Troy’s mother have stated that they were not in a hurry to take Troy back home, still why the
child was discharged, when he could have been asked to stay in the hospital. As per standard 4 of
the Australian nursing standards, documentation is a valuable method of demonstrating that the
nurse have applied the nursing knowledge and judgment within a client and nurse relationship
(Orosz et al, 2014) Nurses are legally obligated to maintain a quality documentation of the
records for promoting safe client care. Again, it the nursing documentation that serves as a legal
document and can be used as a legal document in court during any proceedings of professional
conduct.