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Introduction
Margaret Lavery
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
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
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?
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
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
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
References
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
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/