Don’t just simply ‘follow the form’
Don’t just simply follow the form’
Thorough documentation needed to assess patients
A nurse was conducting a preoperative assessment of a Vietnamese patient. For race, the form had three choices: White, African-American, and Hispanic. The nurse checked "White."
Because staff were not alerted to his correct race, they didn’t think to question whether the patient might have a background health condition. Unfortunately, that patient had hepatitis, which is two-thirds more common in Southeast Asian patients, says Claire C. Yoder, BSN, JD, consultant and partner for Vanot Consulting, Risk Management Services, in Highland Village, TX. "I don’t think the [health care] system should encourage people to follow a form and make it work," Yoder says.
Forms such as the one mentioned above limit the range of choices for practitioners and limit the possibility that they’ll check the diagnosis or properly assess the patient, she says.
In the effort to reduce documentation, some facilities have reduced the history and physical (H&P) to a bare-bones document that lacks the patient information, which nurses need for assessment, says Althea Dunscombe, RN, PhD, CRNFA, staff nurse at the Cleveland Clinic in Naples, FL. "We’re making an extra effort to talk to the physicians when we don’t feel we don’t have adequate H&Ps on patients to find out more about them," she says.
Physicians often think that as long as they know the patient’s background, a brief documentation for the nurses is sufficient, she says. However, "we’re responsible for patient care and patient safety," Dunscombe says. "That lack of information makes our job very difficult."
To avoid medical errors, don’t allow clerical staff to collect lab or X-ray reports, Yoder suggests. Organizations that are responsible for lives, such as the National Aeronautics and Space Administration, normally do not put unit clerks in charge of critical pieces of information, Yoder points out. "You probably should not have that going on in your system," she advises.
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