Question

Documentation

Recently a training was held by an outside organization for the care team at the skilled nursing facility in which you are the manager at. This training focused on the importance of documentation, and their motto was "if it wasn't documented, it didn't happen." After the training was held, one of the medical assistants asked to speak with you. She related that a few days ago, one of the nurses gave a patient their insulin injection but didn't document it in the chart. She stated that she asked the nurse if she would add that information in and was told to mind her own business. Later that evening, the new shift nurse noticed no injection was documented and gave one after the evening meal. The MA stated she kept an eye on the patient and noticed he was very agitated throughout the evening and had a difficult time going to sleep.

• What would you do to handle this situation?

Please be sure to validate your opinions and ideas with citations and references in APA format.

Answer 1

An ERP software implementation (eg - SAP) at the nursing station would go a long way in solving the documentation issues that seem to persist. The nurse, if she had to get the insulin from the pharmacy would have to enter the quantity,patient id/name before getting it issued. This is another way of inventory or stock management at the pharmacy wherein the software automatically reorders the item once it reaches a defined reorder point which is nothing but the lowest stock limit.

The system should be in such a way that once an item is issued on a a patients account, it triggers a communication to the doctor in charge as well as the next shift in charge and the system warns against reissue of the same item within 24 hours. This is just a warning and the nurse/doctor can bypass this instruction as it is not mandatory for all medicines. By this way, the next shift personnel will exactly know the history of the medication of the patient and can take a call on the same as well as every action is documented and it doesn't have the disadvantages/risk of manual entries.