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My thoughts on maintaining good record keeping

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There appeared to be no evidence of the Staff nurse implemeting the principles of record keeping. The Staff nurse should not have allowed the student nurse to give the patient medication without ensuring that she (the student nurse) was competent enough and was taught the correct protocols involved in administering drugs to the patient. In my experience as a nurse I have realized that good record keeping is essential in patient care. Both paper and electronic record keeping is used in my hospital and when done efficiently are readily available for patient care.

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It is very important to ensure that proper documentation and record keeping is done in any healthcare setting in order to protect the staff and health institution from negligence claims as well as provide safety of the patient and for continuity of care . In this scenario nurse Smith failed to apply the principles of record keeping due to staff shortage on a busy unit . This however is no excuse for not following protocols and cannot be used as a defense against litigation should the patient take legal actions for the nurses error . Good record keeping can be used as a baseline for comparison with future data . It also prevents error and allows for continuity of care as well as serves as a tool where nurses communicate . There should have been records of the patient vital signs on admission so as to establish a baseline ; because there were no records to show it is unclear as to whether the error of wrong medication was the reason for the patient's elevated blood pressure and palpitations. Despite the error the patient was still not properly monitored . Nurse Smith at this time should have taken the responsibility to closely monitor the patient instead of delegating that duty to the student nurse who does not understand her task and responsibility as she did not document her observations . Nurse Smith failed to follow protocol which may have pre-disposed the patient to harm . Both nurse Smith and student nurse are accountable for the errors and negligence in this scenario .

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The nurse failed to provide accurate record keeping for the patient upon admission. There was no evidence of baseline vitals for the patient which is important to patient care. These baseline vital signs were needed to help in any further treatment decided for the patient. The important recommendation to reduce medication errors and harm is to follow the rights of medication administration. In this scenario, it was not adhered to. Nurse Smith stated she couldn’t believe the student nurse gave the medication to the wrong patient. The nurse was responsible in supervising and ensuring that the actions of the student nurse does not harm the patient. The student nurse was not competent to administer the drug to the patient. Although the student nurse was delegated to observe the patient, the nurse was solely responsible for reassessing the condition of the patient and recording any changes especially in the absence of the student nurse.

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Staff Nurse Smith did not apply the principles of record keeping. "Care not documented is care not done".  In my experience as a nurse  I have observed that an organization has policies and protocol for safe standards of practice.  (I am  looking at the scenario from the perspective of the International Code of Nurses because care of duty was breached)  'The nurse uses judgement regarding individual competence when accepting and delegating responsibility' (ICN 2012, p3, No. 2c). In my judgement this duty  was not fulfilled by nurse Smith, where the responsibility of a patient requiring close observation after a medication administration  incident had  occurred previously was delegated to a student nurse.

Staff nurse Smith should have eventually taken responsibility for the care of this patient at this point by taking the required measures to safeguard this patient according to (ICN code 2018, p4, No. 4b). In my practice
vital signs and observations are basic records which are required for all patients. It is necessary to  provide the initial baseline assessment for comparisons, to determine any changes in condition; for diagnosing, for communication between all categories staff involved in the patient's care, for continuity of care and is also required in ethical legal situation.  When the patient's condition changed and the Doctor intervened, the absence of documentary evidence showed that no care was given. Even if care may have been given, there was no documentation to show this.

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. The RN should not have left the student to dispense any medication unsupervised which is dangerous and negligent. The student nurse is still in training so it is not wise to do  such a thing. As Rns we must assign tasks to colleagues who are competent enough and is responsible to complete the task. It must be in their job description. Rn should have told the student nurse to hold until she returns from the emergency at hand and do not give any medication. Nurses are accountability to self, patients, public and those in authority. It goes against good nursing practice and professionalism. We must always strive to do no harm, protect the patients and provide safe care. Again a student nurse should not be left alone to monitor and make regular observations on a patient which in this case just had a fall. The Rn should be doing the monitoring and assessment in this case as she is more experienced. Mr Black is priority at the moment and should given all the attention.The RN has been very negligent in the situation so far and is to be helf accountable for further deterioration.

Work not done is work not documented as the law states. The RN should have also instructed the student nurse and even herself should have been recording and documenting the vitals, progress and ongoing assessment of Mr Black. Clearly she hasn’t been applying the principles of good record keeping. She is no doubt bringing harm to Mr Black. Be too busy and burdened by a lot of work is no excuse    and as Nurses we must ensure accurate and timely documentation. This protects the staff, patients and organization from litigation. The RN will have be accountable for her actions in not documenting and leaving the student nurse who is still in training to monitor and assess the patient. Something which requires great skill and experience.
In my work area I strive at times to document accurately on time and professionally. Work not documented is work not done after all.

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The registered nurse has no excuse for the harm caused by the student nurse.She would have told the student nurse not to administer any medication till she comes back.The RN failed because two identifiers were not use in the administration of the medication.
It is the utmost responsibility of the RN,that the patient was assessed on admission and documented,because not documentated means it was not done.
The Registered nurse should know that the patient was her duty of care and not delegating it to the student nurse without supervision.
Therefore all this makes the RN responsible and accountable for the harm caused by the student nurse.

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The Rn is responsible for not only herself and her actions but that of the student nurse as well. She is also responsible for the care and safety of her patients. By allowing the student nurse to administer medication on her own she placed her patients at risk. She should have ensured that the student was supervised and that the medication administration rights were observed prior to administering the medication. The Rn need to ensure also that a proper assessment of her patients were done, as this is one way to note significant changes that can indicate the patient is in distress. In addition to this there was no proper documentation of interventions carried out for the patient. In a case where there is some legal aspect or investigation, the Rn has nothing to keep her or defend herself from litigation. This we have seen is one of the reasons for proper documentation. According to the ICN code of ethics the Rn acted against the standards and guidelines of professionalism. She can be held accountable for her actions and inactions.

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RN Smith failed to apply many  principles of record keeping.
Her statement was not dated or timed, it should have been completed at the time or as soon as possible after the event, noting if it was written after the event. She did identify problems that day (short staffed) and should have mentioned the steps taken to deal with this. Instead of placing blame RN smith needs to be accountable for her decision to delegate the medication administer to the student nurse. When delegating tasks make sure that the person fully understands the instructions.

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The RN is responsible for the patient and student no good documentation was done. The Rn took out medication and was not present when it was administered which is a legal medication error. The NMC states that all nurses must practice within their scope of competence. The RN will be held responsible. Without admission records the patient status as well as care and management is unrecorded.

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The RN is responsible for the patient and student no good documentation was done. The Rn took out medication and was not present when it was administered which is a legal medication error. The NMC states that all nurses must practice within their scope of competence. The RN will be held responsible. Without admission records the patient status as well as care and management is unrecorded.

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The RN is the one responsible for the patient and student nurse.The student nurse should not have been allowed to administer any medication on her own. the RN could have simply asked the student to wait for her and when she is done they will administer the medication together making sure that the medication is given properly for instance double checking the medication, ensuring that it is given to the right patient by using two forms of identification , making sure that the medication is given at the right time and in the correct dose. Proper record keeping would require that both the RN and the student sign the medication chart and the RN would have to cosign the documentation stating that the medication was given.

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The RN is the one responsible for the patient and student nurse.The student nurse should not have been allowed to administer any medication on her own. the RN could have simply asked the student to wait for her and when she is done they will administer the medication together making sure that the medication is given properly for instance double checking the medication, ensuring that it is given to the right patient by using two forms of identification , making sure that the medication is given at the right time and in the correct dose. Proper record keeping would require that both the RN and the student sign the medication chart and the RN would have to cosign the documentation stating that the medication was given.

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The RN is the one responsible for the patient and student nurse.The student nurse should not have been allowed to administer any medication on her own. the RN could have simply asked the student to wait for her and when she is done they will administer the medication together making sure that the medication is given properly for instance double checking the medication, ensuring that it is given to the right patient by using two forms of identification , making sure that the medication is given at the right time and in the correct dose. Proper record keeping would require that both the RN and the student sign the medication chart and the RN would have to cosign the documentation stating that the medication was given.

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In order to ensure safety of the organization, staffs and patients it is important to make sure documentation and record keeping is maintained in every stage. In regard of staff Anne Smith did not follow principles of good record keeping due to shortage of staff and being busy however, it should be known that we have to follow the protocols’ for continuity of care, communication between staffs and as a references, also in ethical legal aspects in medical practices. 
Without having the records of admission means they were dealing with the patient who the status was not known as they may think the cause of changes was due to wrong drug given while not, still after medication they didn’t make follow up until the patient complained. It seems the RN was delegating the tasks to student without references as a base of managing patient and also the student was neither using document in managing the patient nor was not keeping records for condition of patients.

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In this scenario, the staff nurse despite being under pressure and short staffed should not have delegated the task of medication administration to a second year nursing student because as the NMC code of ethics states, only delegate tasks and duties that are within the other person's scope of competence and making sure they fully understand the instructions given. During medication preparation, the staff nurse should have informed the student of the patient that the medication was to be administered to and she should have also reiterated this information before she left the task of administration to the patient. However, under normal circumstances, all students should be supervised always. The RN refused to take accountability for her actions. Also, from admission, documentation was lacking because the patient was not assessed effectively and there was no baseline BP. Due to the ineffective record keeping and the inappropriate delegation, the patient suffered and had to be transferred to CCU. 

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In this scenario, the staff nurse despite being under pressure and short staffed should not have delegated the task of medication administration to a second year nursing student because as the NMC code of ethics states, only delegate tasks and duties that are within the other person's scope of competence and making sure they fully understand the instructions given. During medication preparation, the staff nurse should have informed the student of the patient that the medication was to be administered to and she should have also reiterated this information before she left the task of administration to the patient. However, under normal circumstances, all students should be supervised always. The RN refused to take accountability for her actions. Also, from admission, documentation was lacking because the patient was not assessed effectively and there was no baseline BP. Due to the ineffective record keeping and the inappropriate delegation, the patient suffered and had to be transferred to CCU. 

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RN Smith is the resister nurse assign to the patient and is hence responsible along with the student nurse for the medication error and her documentation has failed to maintain good record keep. Firstly  her statement is not dates and timed, events are not in chronological order, her statement is clear it was short staff but she could of avoid personal speculations stating the second year student should of know how to administer drugs. Her records was incomplete there was no admissions observation notes documented. RN smith is responsible for the patients and the staff under her supervision and should ensure task is delegated to competent personal.

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RN Smith is the resister nurse assign to the patient and is hence responsible along with the student nurse for the medication error

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The RN refused to take any responsibility for the students actions and is basically stating that she should not be held accountable although she was the senior in charge at the time. Also, the lack of opening vitals were omitted from the patient’s notes, therefore the doctor will have nothing to compare the present vitals to, thus thwarting the doctor’s ability to care for the patient effectively. Also, it is important to have accurate records to ensure the continuity of care when the patient is sent to the CCU. The lack of appropriate record keeping could endanger the patient’s life. After making such an error of administering medication to the wrong patient, the nurse should not have delegated the task of observation to the nursing student. The RN is ultimately responsible and accountable for everything that happened to the patient, and everything that can happen to the patient, therefore she should have taken over the patient’s care. The nursing student left for lunch, leaving the patient unattended for 30 minutes, clearly she was not responsible enough to take the initiative to inform the RN she was going to lunch and that the patient would need monitoring in her absence. And also, the RN should be aware that the student went to lunch and taken over. These actions are not in accordance with the ICN Code; the patient health care should be the priority and the nurse must do her utmost to maintain the nursing standards.

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Firstly, unfortunately there was no documentation at all according to the scenario.  Hence there wasn't any information to compare with, that would help to identify risks and enables the early detection of complications. The staff nurse fail to adhere to the ICN code regarding documentation. Secondly the nurse failed to take responsibility for poor admission process and  the delegation of responsibilities along with the  following up. It should not have been the student nurse responsibility to monitor the patient considering the medication error. The staff nurse fail to use judgement  and as a result the patient suffered for it.

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The code of conduct in reference to record keeping and safety are not being adhered to in accordance with the NMC. 

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The code of conduct in reference to record keeping and safety are not being adhered to in accordance with the NMC. 

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It is essential that on admission, a client's vitals are recorded as baseline data . In failing to do so , the nurses have limited the proper planning for future care to the patient,  as baseline data can be use as a reference as to whether patient's condition is improving with current treatment.  Although the staff nurse tried to prioritize the safety of the patient who had fallen, she indirectly placed another patient in harm when she delegated the student nurse to administer the medication to a client assuming that the student nurse was competent enough to do so. Proper supervision should have been given to the student and the staff nurse now becomes accountable for any harm which may have occurred from the medication error. The student nurse is responsible to her actions as she should have sought clarity from the nurse. If she was indeed in doubt of whom the medication should have been administered to she should have waited for the nurse. Also it is the student nurse's responsibility to recall what she had learned about medication administration. She should have used the "Rights" approach ensuring that all the right aspects of the drug administration were present before actually administering the drug.  The nurse however showed that she had the fallen client's best interest by first contacting with the attending physician and providing regular updates on the client  and then delegating the student nurse to closely observe the client. There is a lack of communication though between the staff and student nurse. This is reflected by the lack of continuity of care shown when the client was not observed for the 30 mins that the student nurse too her break. she should have notified the staff nurse of her intentions so that another staff could have taken over until her return.  Short staffing may be a challenge to proper record keeping but should never be accepted as an excuse .

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The staff nurse erred from the very beginning when she failed to follow the ICN code regarding good documentation, due to the fact that there were no baseline data available for comparisons to made which speaks directly to a poor admission process. The staff nurse based on the code failed delegate nursing duties appropriately , i.e. the student nurse administered medications to a wrong patient (which she clearly was not competent to do) and then she was still given the role of monitoring that patent for adverse side effects which she failed again to do properly when she left for a 30mins break without telling the staff nurse she was leaving so that the duty she was given can be delegated to someone else in her absence. (breakdown in communication) After the incident the nurse did follow a few of the codes by directly and immediately reporting the incident to the patent's attending physician so that appropriate measures can be taken. At this point she did document though still a bit sketchy.

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Record keeping scenario.   Good record keeping was clearly not displayed or neither the students nurses part not the staff nurse. Not only did they fail to document the findings of the observation but the patient was left for 30 mins without any observation carried out. The nurse is clearly trying not to be held accountable by shifting the blame on the student nurse when she should have ensure that the student knew exactly which patient was to receive the medication before leaving to assist the other patient.

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Good Recording Keeping When evaluating Nurse Smith statement it did not met some the principles of recording keeping in the nurse’s code. The documentation appeared inaccurate from the time of admission .She identify the risk which occurred and took the necessary steps to inform the doctor and she did complete the records of the incident but at which time was the record completed, and  does she not have a first initial to use when signing  documents .The records were completed with some inaccuracies there were many omissions in time, date, location and the name of staff. If instructions form the doctor was verbal or written.There is no indication on what time the student nurse went to lunch and who she handed over the patient care too and how often the vital signs readings needed to be recorded.  There was no need to state the behaviour of the doctor. The transfer of the patient to ICU was done but no time was indicated, the condition of the patient at the time if transferring and who transported the patient.The statement was poorly written.

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Good Recording Keeping When evaluating Nurse Smith statement it did not met some the principles of recording keeping in the nurse’s code. The documentation appeared inaccurate from the time of admission .She identify the risk which occurred and took the necessary steps to inform the doctor and she did complete the records of the incident but at which time was the record completed, and  does she not have a first initial to use when signing  documents .The records were completed with some inaccuracies there were many omissions in time, date, location and the name of staff. If instructions form the doctor was verbal or written.There is no indication on what time the student nurse went to lunch and who she handed over the patient care too and how often the vital signs readings needed to be recorded.  There was no need to state the behaviour of the doctor. The transfer of the patient to ICU was done but no time was indicated, the condition of the patient at the time if transferring and who transported the patient.The statement was poorly written.

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There was poor documentation from the day of admission because the vital observations were not recorded.
Chances are that the medication chart for the patient was not properly labelled to help the student to identify the right patient who was supposed to get the medication.

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Record Keeping
Patient records where not documented accurately from admission as they was no  record of blood pressure on admission.Secondly ,the student nurse was not supposed to be allowed to give medication without proper supervision and the code clearly state not to assume someone is competent .The nurse was suppose to monitor patient condition when the student went on her break or delegate to someone .The nurse statement did not clearly give account of what happened and some information where missing .The statement was written using informal language .

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Discussion on scenario on record keeping

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Discussion on scenario on record keeping

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As noted in the scenario no admission observation and documentation was done which is one of the recommended criteria for effective record keeping. Therefore the nurse has no baseline vitals or documentation to compare with, when the patient starting feeling sick after being given the medication. Labeling (patient’s name, bed number and name of medication) was not done, otherwise the student would have information to compare with the patient she was giving the medication to. On the other hand the student nurse should not be administrating medication without the supervision of a registered nurse. Documentation was not done of the incident and the verbal (subjective) complaints reported by the patient and objective such as elevated blood pressures and palpitation and also the time those events occurred. The patient was asked to be monitored and documentation of what occurred during observation was recorded. The registered nurse in the scenario did not do proper documentation according to good record keeping by the Nursing and Midwifery Council.