Nursing Case Study: Patient Care, Documentation, and Legal Aspects

This case study analyzes a nursing scenario involving an enrolled nurse, Rose Baxter, and her responsibilities towards two patients, Mr. Smith and Mr. Smythe. It examines the nurse's duty of care, highlighting the potential breach due to a documentation mix-up. The study explores implied consent demonstrated by Mr. Smith and emphasizes the importance of open disclosure in discussing incidents that could harm patients, including its benefits in restoring trust and encouraging patient involvement. Furthermore, the assignment details the significance of documentation in healthcare, including legislative requirements, quality improvement, research, and communication. It includes a filled-out clinical incident report and stresses the importance of nurses' knowledge of laws, legislation, and organizational policies to ensure professional compliance and patient safety. The references provided support the key concepts discussed, such as duty of care, open disclosure, and quality nursing documentation.

Running head: NURSING 1
Nursing
Name
Institution

NURSING 2
Case Study
Question 2
The duty of care of a nurse is the professional obligation that is placed on nurses to ensure that
they perform their duties in conformity with some established standards (Cornock, 2014). The
enrolled nurse, Rose Baxter had a professional duty of care to look after both Mr. Smith and Mr.
Smythe. Since their names sound almost similar, she had to ensure that no mix up occurred thus
guaranteeing the safety of both patients. This duty of care was however possibly breached when
a mix up occurred in the theatre documentations.
Question 3
The type of consent displayed by Mr. Smith could be described as implied consent. He consents
to the requirements of the enrolled nurse by holding out his arm to get ready for a prick of the
finger for the test of the blood glucose level. The reason this type of consent is described as
implied consent is because Mr. Smith, without saying a word stretches his arm out which is a
clear indication of his wish to the enrolled nurse.
Question 10
Openly engaging a patient in all discussions regarding the several incidents that could possibly
endanger or harm them is known as open disclosure. Eaves-Leanos & Dunn (2012), confirm that
even the family if the patient can be involved in an open disclosure. It is important to note that
open disclosure is well within a nurse’s scope of practice. It could be beneficial to engage Mr.
Smythe in an open disclosure regarding the near miss in a number of ways that include;
amending feelings of, grief, anger or helplessness guilt, restoring the trust between a patient and

NURSING 3
a nurse, and it also encourages the patients to take an active role in discussing the ways of
improving the quality of healthcare (O'connor, Coates, Yardley & Wu, 2010). As a nurse, it is
important to note that the patient-nurse trust could be ruined if the information is hidden from the
patient and he finds out later.
Question 13
i. Attainment of all the necessary legislative requirements
ii. Facilitation of how to improve quality in a healthcare system
iii. Documentations are also used to conduct pieces of research in the future Jefferies,
Johnson & Griffiths, 2010).
iv. Communication between the providers of healthcare and healthcare practitioners by
guaranteeing that everyone gains access to the required information.
v. A sequential order of documentation in the health records of the patient
Question 14
CLINICAL INCIDENT REPORT
Client Name: Mr. John Smythe DOB: 6/9/1945
Incident type
(Circle
appropriate type)
Actual Potential
Date 15th April 2015
Time 0810 hours
Location Theatre
Description
The nurse being given a documentation form for skin lesion and a medication order
for IV antibiotics. The form however has the details of Mr. John Smith instead of
Mr. John Smythe.
Reported to: The incident is reported to the attending doctor.
Signature and
role:
Enrolled nurse taking care of Mr. Smythe

NURSING 4
Question 15
It is crucial that I demonstrate my knowledge regarding the available laws and legislation that
govern the role and practice of an enrolled nurse. As a nurse, it is additionally essential that I can
express my understanding of the policies and procedures of my organization that are useful in the
practice of an enrolled nurse. This will help me in ensuring that I can comply with my
responsibilities as a professional.

NURSING 5
References
Cornock, M. (2014). Duty of care. Orthopaedic & Trauma Times, (24), 14-16.
Eaves-Leanos, A., & Dunn, E. J. (2012). Open disclosure of adverse events: transparency and
safety in health care. Surgical Clinics, 92(1), 163-177.
Jefferies, D., Johnson, M., & Griffiths, R. (2010). A meta‐study of the essentials of quality
nursing documentation. International journal of nursing practice, 16(2), 112-124.
O'connor, E., Coates, H. M., Yardley, I. E., & Wu, A. W. (2010). Disclosure of patient safety
incidents: a comprehensive review. International Journal for Quality in Health
Care, 22(5), 371-379.