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Health Care Policy Analysis

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Legal Risks of Nurses
Caroline Walker
MHA622: Health Care Ethics & Law
Instructor: Judy Roberts
September 16, 2013

The primary focus of documentation and recording is to facilitate information flow that supports continuity, quality, and safety of care, recordkeeping systems serve multiple purposes. Also information about a patient, once recorded is not easily accessible or available and unstandardized format clinician’s owns words resulting in many errors and misinterpretation.   Studies focus on improving documentation proficiencies.   Nursing records have shown problems with accurately representing the patient with time consuming nature of recording completeness a series of interventions is aimed at improving nursing documentation.   The changing nursing documentation comes from several sources such as hospital management, compliance with legal mandates and paperwork reduction campaign.. In the reading of patient Mr. Ard who was in the hospital because he was nauseous and in pain and had shortness of breath his wife was ringing the call light because she wanted the nurse to come in and give him some relief, finally the nurse showed up but fail to ask was he allergic to any medication and   just administered him something for nauseous the nurse fail to read the physician progress note that give the information about Mr. Ard aspiration problems. The nursing staff fail below the standard of care that is due to all patients, also it was negligence on their part to all of this could have been avoided if the plan of care was followed correctly. I know before each shift of nurses comes on to work they have to report to the new nurse that will be taking care of the patient. Also nurses are to make rounds every 4 hours depending on the illness of the patient and none of this was mention in the care of Mr. Ard. (Pozgar, 2012)   A growing number of nurses becomes employees for a group of practice such as (HMO) retail clinic or other types of health care system...

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