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Cindy Smith, RN, has been working on different units within the hospital and has system access...

Cindy Smith, RN, has been working on different units within the hospital and has system access to those units. She was assigned to care for Zack Kramer a few days on the Cardiac Step Down Unit. Today while working on the Medical Surgical Unit, Cindy accessed Mr. Kramer’s record to see how he was doing and to see if he would be discharged soon. Is this appropriate? Why or why not? While Cindy is reviewing Mr. Kramer’s record she realized that she did not complete documentation for Mr. Kramer’s physical assessment. Would it be acceptable for her to complete the documentation information? Why or why not?

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Answer #1

Yes she can visit and review the patient as it depends on the hospital policy. Follow up care can be done by a nurse for her patient untill he is discharged.

It is not acceptable for her to complete her previous document as it would be a malpractice were by the documentation is not valid. The patients state presently may be better comparatively to previous and it cannot be recalled and wrote. Better she could inform the incharge about the incident and go further.

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