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Case Study: Late and Later Documentation

 According to what you learned from chapter 3 critique the documentation presented by the healthcare provider and provide examples of whether the nurse followed or did not follow documentation requisites.

Case Study: Late and Later Documentation:

The following is a case study in which documentation played a role in the practice breakdown of nursing care. The story is encapsulated for the reader with a sample of the actual documentation provided by the nurses involved. The reader is encouraged to question whether the documentation truly reflects the story presented. According to what you learned from chapter 3 critique the documentation presented by the healthcare provider and provide examples of whether the nurse follow or did not follow documentation requisites


Ms. Amy Jones was a 55-year-old woman being treated for depression at a mental health facility. She was alert, oriented, ambulating without difficulty, and interacting appropriately with staff. The patient’s family was scheduled for a meeting with her treatment team in the afternoon. During the day Ms. Jones met with her psychiatrist, Dr. Ian Smith, in Ms. Jones’s room. When her roommate came in, Dr. Smith suggested that they complete their session in his office, and Ms. Jones accompanied him to that space. On the way, she complained that she felt weak but could make it. During the session, she reported that she had a headache, which Dr. Smith attributed to anxiety. He went to look for a nurse to provide medication for Ms. Jones. On his return with Ms. Mary Sullivan, a registered nurse, Ms. Jones was on the floor on her knees vomiting. A physician working across the hall came and assisted Dr. Smith and Nurse Sullivan with Ms. Jones, who was now quite somnolent, into a wheelchair. Dr. Allen, the primary care physician, ordered that Ms. Jones be given Phenergan IM for the vomiting and that the nursing staff monitor her bowel sounds. Dr. Allen reported that she was not informed of Ms. Jones’ complaints of headache or loss of bowel control. Dr. Allen thought that she was dealing with gastrointestinal symptoms so she had the nurses check for bowel sounds and softness of the patient’s belly. She reports that she received a second callback and was told bowel sounds were normal, the patient’s stomach was soft, and the patient was resting comfortably. Ms. Jones was bathed and returned to her bed. She took the prescribed Phenergan after which she vomited several more times during that shift. She was incontinent of stool once. No one considered conducting neurologic checks because the staff thought Ms. Jones was suffering from a virus.

When Ms. Jones’s family members arrived, the nurses advised them that their mother was sick and was sleeping, and would not be able to attend the meeting. The family members could not arouse the patient. The staff said that Ms. Jones had been administered Phenergan for vomiting and would be awake by evening. Family members returned that evening and found the patient still unresponsive with vomit in her mouth. The family checked Ms. Jones’ pupils and found them unequal. The family reported to the registered nurse at the desk, and another nurse checked Ms. Jones’ vital signs and reported them to be normal. The family telephoned Ms. Jones’ primary care physician, Dr. Allen, and the nurse gave him a report. Soon after this call, an ambulance transported Ms. Jones to the hospital for evaluation. Ms. Jones subsequently died at the hospital.

Ms. Jones’ daughter stated that the registered nurse did not assess her mother; on arrival in the unit, the EMT assessed Ms. Jones. Ms. Jones’ daughter did not believe that her mother had been adequately monitored from noon to 6:30 PM. She also complained that the nurses were laughing at the family’s concerns about the condition in which they found their mother.

Ms. Cherie Hoffman, a registered nurse, had been employed at the facility for 25 years. She began her career as a nursing assistant, a title she held for 7 years. She then served as a licensed practical nurse for 10 years and then as a registered nurse for the past 6 years. She was familiar with all of the policies and procedures of the facility. On the day of the event Ms. Hoffman was working as the charge nurse; she noted that it was a particularly busy day. She returned from lunch and was informed by Nurse Sullivan that Ms. Jones was ill and had vomited. She was bathed, and the staff had documented her vital signs, completed the Glucoscan, and medicated Ms. Jones with Phenergan per Dr. Allen’s order. The family was not notified of a change in Ms. Jones’ condition because they were expected for a family conference at 3 PM, and Nurse Sullivan hoped that Ms. Jones would feel better by then and could participate in the conference. Nurse Hoffman assisted Nurse Sullivan in monitoring Ms. Jones throughout the rest of the shift. Nurse Hoffman had understood that Ms. Jones had not been sleeping well and thought it would be good to let her sleep. Nurse Hoffman thought Nurse Sullivan had last assessed Ms. Jones at 7 PM.

Nurse Hoffman states she was never informed that Ms. Jones had collapsed prior to vomiting or that she had a headache, or that Ms. Jones was somnolent after the episode. She reported that Ms. Jones had a history of headaches, nausea, and dizziness, all of which had been attributed to medications.

Nurse Sullivan recalls reporting everything to Nurse Hoffman. Nurse Sullivan said she had checked bowel sounds as directed. Ms. Jones was incontinent of stool at 2 PM. and was bathed and repositioned. Around 6 PM. Nurse Sullivan straightened Ms. Jones in bed and said that Ms. Jones looked comfortable. Nurse Sullivan said that she did not feel anxious about the patient, as she thought Ms. Jones was sleeping. Ms. Jones was not on 15-minute checks, but Nurse Sullivan recalled checking on Ms. Jones frequently throughout the shift to assess for vomiting.


The purpose of documentation is to clearly communicate the condition of the patient as well as the assessment, planning, implementation, and evaluation work of nursing.

It is a continual and ongoing process that reflects the changing needs and conditions of the patient.

Documentation is the critical and sometimes only form of communication among all health care providers about the current condition of a patient.


Currently patient care documentation is found in a variety of forms and formats, handwritten and computerized.

Written documentation systems have been developed to assist clinicians to produce accurate and comprehensive documentation. Examples include the following: (a) problem-intervention-evaluation charting (PIE); (b) subjective-objective-assessment-plan charting (SOAP); (c) problem-oriented medical record charting (POMR); and (d) charting by exception formats, outcome-based charting; and critical pathways (
, 1999).

Checklists for exception charting to address the time restraints have been implemented as documentation requirements for regulatory compliance increase.

At times, nurses shortcut documentation because of time constraints or limitations of these forms at the expense of complete charting.


As patient care becomes increasingly complex, the importance of timely and accurate documentation becomes increasingly important.

Delays, omissions, and errors in documentation may result in delays or errors in assessments, interventions, treatments, procedures, and medication administration.

These errors often create a cascade of events that may negatively impact patient care or patient outcome.

Computerized documentation systems

Computerized documentation systems are more than automation of existing paper forms.

State-of-the-art documentation systems are designed to more closely reflect the flow of patient care processes in an orderly way and to increase patient safety within the available features and design.

Computerized clinical documentation systems that support functional requirements contribute significantly to patient safety and caregiver effectiveness.

Computerized documentation systems

Safe nursing practice is supported in the following ways with an electronic record that includes:

Design of documentation systems that more closely reflect actual work processes and patient throughput, supporting clinician assessments and work organization

Integration of physician order entry, medication administration, and clinician documentation systems

Inclusion of a framework that encompasses nursing knowledge functions as a cognitive map for clinicians (nurses handle large amounts of data and often experience overload and stress; also provides professional support in making complex clinical decisions) and increases efficiency (
von Krogh et al., 2005)

Computerized documentation systems

Integration of standards-based organizing frameworks such as Nursing Interventions (NIC), Nursing Outcomes (NOC), and North American Nursing Diagnosis Association (NANDA)

Use of a complex and comprehensive database for patient and nursing research

Inclusion of alerts, popups, and protocols to guide caregivers in both care processes and documentation

Computerized documentation systems

Specific outcomes from computerized documentation that have an impact on patient safety and decrease the potential for practice breakdown include:

Elimination of illegibility

Minimized duplication

Improved response time to patient requests

Computerized documentation systems

Specific outcomes from computerized documentation that have an impact on patient safety and decrease the potential for practice breakdown include:

Improved documentation completeness

Increased compliance with regulatory requirements (e.g., assessments for pain level, skin integrity, and fall risk)

Simultaneous, real-time access to up-to-date patient data for multiple clinicians

Computerized documentation systems

Issues with computerized documentation:

If there are rigid rules for documenting the administration of medications within one-half hour of administration, and the patient-to-nurse ratio is too high, the nurse may be tempted to document before actually administering the medication.

This sets the patient up for undetected “missed doses” of medication.

If the workflow and patient care record are poorly designed, requiring excessive amounts of time for access, then nurses may not have a chance to document their assessments and treatments in a timely manner.

Nondocumented therapies place patients at great risk for second doses of narcotics, sedatives, or other medications.

Computerized documentation systems

Issues with computerized documentation:

The down side of the extensive requirements for documentation in today’s complex hospitals is that the nurse can spend from 13% to 28% of his or her time in patient care documentation, and this reduction in the nurses’ availability to provide direct patient care has been shown to diminish patient safety (
et al., 2003
Pabst et al., 1996
Page, 2004).


Discuss the HISTORICAL CASE STUDY described on Ebook:
Nursing Pathways for Patient Safety(Page 50)



G.M. Keenan, E. Yakel, D. Tschannen, M. Mandeville: Documentation and the nurse care planning process. In R. Hughes (Ed.): Patient safety and quality: A handbook for nurses. 2008, Agency for Healthcare Policy and Research, Rockville, MD, 1–33, Available online at, Accessed 10-30-2008.

G. von Krogh, C. Dale, D. Naden: A framework for integrating NANDA, NIC, and NOC terminology in electronic patient records. Journal of Nursing Scholarship. 37(3), 2005, 275–281.

In A. Page (Ed.): Keeping patients safe: Transforming the work environment of nurses. Committee on the Work Environment for Nurses and Patient Safety, Institute of Medicine 2004, The National Academies Press, Washington, DC.

L. Korst, A. Eusebio-Angeja, T. Chamorrow, C. Aydin, K. Gregory: Nursing documentation time during implementation of an electronic medical record. Journal of the American Medical Association. 33(1), 2003, 24–30.

M. Pabst, J. Scherubel, A. Minnick: The impact of computerized documentation on nurses’ use of time. Computers in Nursing. 14(1), 1996, 25–30.

S. Meiner: In Nursing documentation: Legal focus across practice settings. 1999, Sage, Thousand Oaks, CA.

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