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Case Application - Documentation & Allocation of Resources

Pat Smith, RN provided discharge instructions to a client with a halo fixation. However, her documentation was missing key details such as the date, client's condition at discharge, and education provided. As a result, the client's pin sites became infected as he was unaware of the cleaning requirements. Proper documentation is crucial to avoid errors and ensure patients understand care. Both Pat and the hospital may be held accountable, as nurses are responsible for mistakes and organizations must address errors to guide staff actions and ensure patient safety.

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Jennessee Miague
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45 views3 pages

Case Application - Documentation & Allocation of Resources

Pat Smith, RN provided discharge instructions to a client with a halo fixation. However, her documentation was missing key details such as the date, client's condition at discharge, and education provided. As a result, the client's pin sites became infected as he was unaware of the cleaning requirements. Proper documentation is crucial to avoid errors and ensure patients understand care. Both Pat and the hospital may be held accountable, as nurses are responsible for mistakes and organizations must address errors to guide staff actions and ensure patient safety.

Uploaded by

Jennessee Miague
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Jennessee Miague BSN 2-D

Case Application - Documentation & Allocation of Resources

Pat Smith, RN provides discharge instructions for a client with a Halo fixation who is
leaving the hospital to go home. Pat educates the client on pain medication, self-care
(including pin site care) and informs him of the signs and symptoms of infection. Pat
also schedules a follow-up appointment and gives the client a discharge instruction
sheet. During the follow-up appointment in the out-patient clinic, Kim Jones, RN
determines the pin sites are infected. The client says he was not aware that he was
supposed to clean the Halo fixation pins. Kim reviews the electronic medical record and
sees the discharge documentation of Pat Smith as follows:
3PM: Vital signs revealed T = 36"C, PR = 80, RR = 20 and BP 120/90
mm/Hg.
3:30PM: Discharge instructions given together with his wife and was clearly
understood. Discharged
per wheelchair in an improved condition.
The patient was brought to the emergency room and dressing of the pin sites were done
and was given a complete dose of antibiotics for free. Pat's attention was called by the
Nurse Supervisor regarding her discharge notes.
Answer the following questions briefly and concisely:

1. What have you noted about the documentation of Pat Smith, which led to the condition
of the patient?

 There are missing elements in his documentation which includes the date in full
by month-day-year, the client’s condition at discharge, any teaching or education
for self-care as well as care provided from the time the client entered the health-
care system until his discharge.

2. What would be our lessons here as nurses in relation to documentation. What could
have been done by Pat Smith to avoid such case to happen?

 It is necessary and integral aspect of the work of us nurses to ensure clear,


concise and accurate documentation. The lesson in Pat’s case is that it is very
crucial to articulate and reinforce principles that are basic to effective
documentation to avoid malpractice as well as error or negligence on behalf of
the nurse which will cause things to go wrong with patients. To avoid things to
happen, ensure that every detail of what was done has been documented
correctly and accurately.
3. Will the hospital & Pat be accountable to what happened to the patient? Why? Why not?

 Nurses are just as accountable to their mistakes as they are to their practice. So
yes, Pat is accountable to what happened to the patient. Since there was a
malpractice and negligence in the case, Pat needs to be aware of the legal
obligations connected to the provision of patient care where the patient have a
right to expect them to hold insurance or may be entitled to compensation. On
the other hand, the hospital will be held accountable for the actions of their staffs,
the organization will have to track these errors and gather information through
occurrence reports/incident reports/patient safety events to guide Pat’s actions.
B. Case Application: Allocation of Resources
Answer the following questions briefly and concise - at least 3 to 8 sentences.

1. A certain victim of "hit and run" is rushed to a private hospital emergency room for
urgent and immediate medical intervention where only one resident, along with one ER
nurse is on duty. The said victim arrives together with the arrival of a patient who is
highly febrile. Whose right to immediate medical intervention is deemed greater? Why?

 The patient who is a victim of “hit and run” deemed greater right to immediate
intervention because the case was an “emergency” and delay of the treatment
may cause death or disability. In addition, it was in the law, specifically in the
Republic Act No. 8344 that hospitals and medical clinics must administer
appropriate initial medical treatment and support in emergency or serious case.

2. in catastrophic situations or disaster like an earthquakes where there is limited medical


practitioners & equipment, who will be given medical intervention first by the medical
team? Why?

 Patients whose lives are in immediate danger and who require immediate
treatment are to be given medical intervention first. These are patients with
serious wounds, resuscitation, and needing immediate surgery-life saving-and
have a good chance of survival.

3. Compare the micro-allocation (Case#1) and macro-allocation (Case #1) of resources in


terms giving medical intervention on the cases mentioned above, what have you
observed

 I have observed that micro-allocation focuses on decisions regarding particular


persons, involves bedside decisions regarding the distribution of a limited
number of medical resources to specific patients. While macro-allocation occurs
at the societal level, involves decisions about how to distribute resources among
several public goods.
REFRENCES:

Wilson, B. B. (2021). Why Is Documentation Important in Nursing? The Nerdy Nurse.


https://thenerdynurse.com/why-is-documentation-important-in-nursing/

(n.d.). https://www.encyclopedia.com/science/encyclopedias-almanacs-transcripts-and-
maps/healthcare-resources-allocation-i-macroallocation

Wilson, B. B. (2021). Why Is Documentation Important in Nursing? The Nerdy Nurse.


https://thenerdynurse.com/why-is-documentation-important-in-nursing/

American Nurse. (2019). Promoting professional accountability and ownership.


https://www.myamericannurse.com/promoting-professional-accountability-ownership/

(n.d) https://wadem.org/wp-content/uploads/2017/06/Triage-During-an-MCI.pdf

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