You are on page 1of 5

Running head: DOCUMENTING IN NURSING 1

Introduction
Margaret Lavery

James Madison University


DOCUMENTING IN NURSING 2

Introduction

Documenting is an essential part of the health care profession. Although the evolution of

computerized documentation has advanced the medical field, it still comes with drawbacks.

Nurses describe “the EHR is seen by nurses as both a benefit and a source of considerable

frustration.” (Lavin 2015) Considerable errors from the miscommunication in documentation can

lead to detrimental patient’s outcomes. (Wolff 2008) Miscommunication in nursing results in

negative patient outcomes and leaves the hospitals in a vulnerable position.

Background

During a break from school I had the opportunity to shadow a nurse, she was

demonstrating how to document properly and noticed how the nurses on the previous two shifts

had documented the same things. She explained to me that there is an option to copy and paste

the nurses work before you, but it should never be done because the patient rarely stays the same

over a twenty-four-hour period. We were discussing how conflicted we both were on whether or

not to report the issue. I explained how it could severely impact the care of the patient if their

records weren’t being properly tracked but at the same time if the nurse before-hand read those

and felt that they were still true it is up to the discretion of the nurse to keep those records, even

if she didn’t originally think of them.

We decided to no report the issue and just document what we found throughout the shift.

The alternate to the situation was to either go to the nurse to explain our concerns or report it up

the hospital chain of command. We chose to do neither. This situation caused moral distress on

me because I knew the correct course of action was to speak with the nurse directly, but I acted

against it. I knew that I did not act in my best judgement in this situation because the interest of
DOCUMENTING IN NURSING 3

the patient was not put first. The patients best interest should always be at the forefront of any

ethical dilemma.

Methods.

James Madison’s eight key questions are a great resource to evaluate an ethical situation.

(The Madison Collaborative 2013) These open prompts allow for flexible and dynamic critical

thinking in all areas. The first of the eight is, fairness. This is prompting how one can ask in

everyone’s best interest. Next, are outcomes, which is considering what the best short and long-

term outcomes are. Responsibilities, asking what duties apply in this situation whether it be your

duties, or someone else’s. Character, this is prompting you to act in the way that best represents

yourself and who you want to become. Liberty, how does your decision respect freedom,

personal autonomy, and consent? Empathy, would you act differently if it was someone you

cared deeply about? Authority, what does the policy, law, and/or a higher power expect of me?

And lastly, rights, what rights apply?

In my ethical situation I found all of the eight key questions to apply. First, fairness, I

favored the interests of the nurse over the patient’s best interest. The patient was not being

treated fairly because her status was not being documented accurately. Outcomes, this goes along

the same lines as fairness, I considered the outcome of the nurse over the outcome of the patient.

This had a considerable impact because the nurse will continue to do this with other patients in

the future which puts them at risk. Responsibilities, whether it be as a nursing student or as a

nurse I have a duty to the patient to keep their best interest in mind. Character, I showed poor

character by not standing up for what was right. Liberty, the patient was not fully respected

because that nurse did not take the time to carefully document what was actually happening in

her situation. Empathy, the nurse and I both acted without much empathy because I would expect
DOCUMENTING IN NURSING 4

better care for my loved ones. Authority, the hospital policies and laws both expect health care

professionals to act in an ethical way and document truthfully. And lastly, rights, the patient had a

right to a care provider who has her best interests in mind.

In the American Nurses Associations Code of Ethics, provision 3.6, Addressing impaired

practice, states “Nurses must be vigilant to protect the patient, the public, and the profession

from potential harm when a colleague’s practice, in any setting, appears to be impaired.” (ANA

2015) This code directs the nurse to contact a supervisor along with directly contacting the

colleague in discussion to support and help guide them. If the care continues to falter, then it is

the responsibility of the nurse to report this issue so that it is handled.

Conclusion.

Although this situation was morally taxing I felt that I learned a considerable amount and can

apply this to my nursing practice. The eight key questions expanding my thinking and allowed

me to think critcally about the situation at hand. If I could go back to this day I would have made

better decisions and followed the ANA’s Code of Ethics. Regarless of how uncomfotable it

makes you or the other colleguae the patient should always be put first so I should have asked the

nurse to speak with her to resolve it. If the nurse does not properly document the patients

outcomes it can severly impact the patients outcomes. If the nurse isnt accruatley documenting it

can lead to longer hospital stays and put the hospital at risk for liabilites. In the future I will take

what I learned from this situation and know the imporatnce of documenting your own work and

doing so thouroughly because it can dramatically affect the patient.


DOCUMENTING IN NURSING 5

References

(2013). The Eight Key Questions. Harrisonburg: The Madison Collaborative

American Nurses Association. (2015). Code of Ethics. Retrieved March 18, 2018, from

http://www.nursingworld.org/codeofethics

Lavin, M., Harper, E., Barr, N., (April 14, 2015) "Health Information Technology, Patient

Safety, and Professional Nursing Care Documentation in Acute Care Settings" OJIN: The

Online Journal of Issues in Nursing Vol. 20 No. 2.

Wolf ZR, Hughes RG. Error Reporting and Disclosure. In: Hughes RG, editor. Patient Safety

and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for

Healthcare Research and Quality (US); 2008 Apr. Chapter 35. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK2652/