The importance of adequately documenting assessments and
treatment plans was highlighted in a decision published by
Deputy Health and Disability Commissioner Dr Vanessa
Caldwell.
In her decision, Dr Caldwell found two
nurses in breach of the Code of Health and Disability
Services Consumers’ Rights (the Code) for failing to
comply with the Nursing Council of New Zealand (NCNZ) Code
of Conduct for Nurses, and prison service policies for
clinical documentation.
This case concerns care
provided to a man who was found unresponsive in his cell. He
was assessed by a nurse, and the recorded plan was to refer
the man to hospital for follow-up. However, there were
significant omissions in the documentation of the nurse’s
assessment, making it difficult to determine the adequacy of
the assessment. There was no evidence of a physical
assessment of his head, including looking for any
lacerations, bruising, or swelling to the face or scalp, to
determine whether there had been any trauma to the
head.
Failure to undertake these assessments
represented a severe departure from accepted practice,
particularly when the purpose of the assessment was to
determine how the man became unresponsive.
Prison
officers were also asked to continue observation of the man
until his transfer to hospital, but records of any
observations made could not be located by the prison
service.
Another nurse reviewed the man later that
day, and similarly there were omissions and inaccuracies in
the documentation of care provided, including failing to
provide any evidence for making a change in diagnosis from a
possible concussion to a gastric issue and deciding not to
send the man to hospital. These omissions represented severe
departures from accepted practice, and made it very
difficult to understand the patient’s clinical situation
and the rationale for the treatment decisions being
made.
The next day, a GP who subsequently examined the
man determined his earlier loss of consciousness required
further investigation, including a chest x-ray and referral
to a specialist.
In her decision, Dr Caldwell was
critical of both nurses for omissions in documentation of
their assessments of the man. Prison service policies state
documentation in a clinical emergency response should
include all clinical information and actions taken. The NCNZ
Code of Conduct for Nurses states nurses should keep clear
and accurate records of any discussions and assessments
made. In addition, nurses should ensure entries in a
patient’s clinical records are clearly and legibly signed,
dated, and timed. The prison service’s Health Care Policy
also provides the standard for documentation, and requires
that documentation is dated, accurate, and
relevant.
Dr Caldwell says, “I am critical of multiple
omissions in the documentation, and that staff did not
adhere to the documentation requirements of the prison
service’s policies. Documentation should be accurate and
comprehensive to ensure staff have all relevant information
following handovers”.
The prison service has a
responsibility to operate its health service in a manner
that provides consumers with services of an appropriate
standard.
“While I have some concerns about the care
provided to the man, I do not consider the prison service
breached the Code. However, I am concerned about multiple
omissions in the documentation of the care provided to the
man by different staff on different occasions, and the
prison service’s failure to locate any record of
observations made by officers. I consider that this reflects
poorly on the prison service’s record-keeping systems at
the time of the events,” says Dr Caldwell.
Dr Caldwell
made several recommendations, including that the nurses both
undertake training on documentation, and provide a written
apology to the man. She also recommended the prison service
provide evidence that nursing staff have received training
on documentation standards and relevant healthcare policies,
and that it consider the adequacy of guidance and training
currently provided to officers in relation to the
observation of patients with health conditions.
“I
acknowledge the substantial changes made by the prison
service since these events to improve the training provided
to staff, which will improve the standard of
documentation.
“I encourage the prison service to
continue its work in this area, and ensure staff have the
training and tools necessary for accurate and complete
documentation,” says Dr
Caldwell.
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