FUNCTIONS

PATIENT X

SCORE

I.

Application and execution of physicians legal orders 1. Medical Diagnosis Complete

SCORE 7 7 The diagnosis is complete to permit intelligent 3 execution of the nursing functions. However, there were abbreviations. In the case of patient X, the diagnosis was Laryngeal Ca s/p 6th cycle chemotherapy, HPN 2, CAD, Dyslipidemia and Anemia. This was accompanied with the complete International Classification of Diseases 10 code which is the standard diagnostic tool for epidemiology, health management and clinical purposes (WHO, 2013). The physicians orders are clear, explicit and 3 conclusive when looked at in regard to patients diagnosis and other clinical data. Diagnostic tests are ordered in a clear manner but results were not seen in the patients chart. These were: Serum SA, K, SGOT and creatinine. Some medication orders are also incomplete. Here are some of the examples: Metformin 1 tab OD, Vitamin B complex I tab TID, PNSS 1l + MS2 x 12 hours and FeSO4 1 tab TID. Other medications are complete with their corresponding dosages, route and frequency of administration example, Increase insulin to 8 units pre-dinner SQ. According to Viljoen (2005), completeness is very important because it saves time and reduces risks. When a physicians order is incomplete, the person who is giving follow-up consumes more time to confirm the order if not, taking the risk of carrying it out from what he knows. Written orders are better understood and chances of error are minimized if they are clear, specific, complete and legible (Viljoen, 2005). Orders are not current as evidenced by a written 3 order that should be done on October 1, 2012 but it was already written October 2, 2012. Example, October 2, 2012 9pm: # CBG= 245 mg/dl. Increase insulin to 8 units pre-dinner SQ and then the next order is dated 10/1/2012 4:40 pm. The Joint Commission on Accreditation of Healthcare Organization (1994) requires client record documentation to be timely, complete and accurate.

2. Orders Complete

3. Orders Current

4. Orders promptly executed

5. Evidence that the nurse understood the cause and effect

6. Evidence that the Nurse took the health history into account

Orders were carried out at an average range of 103 20 minutes. And some orders were undetermined if what time they were carried out because no time were written both on the doctors order and the time it was carried out. The date was only noted in some of the carried out orders. An example would be, at 10/5/12 11 am, the order was to decrease Wosulin 16 units pre-breakfast and 6 units predinner. This was carried out and signed 10/5/12 but the time was nowhere to be found. Also, the year in both the doctors order and the date it was carried out were missing in 11 out of 16 physician orders. As a practice of record keeping, nurses needs to keep accurate and complete records of nursing care including the time and date provided to clients. Failure to keep proper records can constitute to negligence and be basis for tort liability (Kozier and Erb, 2008). The shows that the nurse knows what she was doing 7 and why she was doing it as evidenced by the patient was on ongoing chemotherapy and the nurse wrote his observation which was not in any form of distress and no adverse reaction to ongoing chemotherapy. Another is the objective cue documented by the nurse was: with episodes of nausea and interventions done were encouraged to eat small frequent feedings and encouraged soda crackers and small frequent sips of fluids and administered due meds. Also, when the patient has undergone blood transfusion, documentation like no reactions to blood transfusion was noted. According to Phaneuf (1976) , a nurse performing any service ordered by the physician is legally obligated to understand the cause and effect of that service before performing it. The nurse is required not only the basis for and anticipated therapeutic results of performance, but also the possible side effects or other complications. The chart reflects recognition that knowledge of 7 pertinent points in the patients past pattern of health and illness are vital to intelligent and current nursing care as evidenced by the charting in the ER: On 2007, the client had been diagnosed of laryngeal cancer and scheduled for the 6th cycle of chemotherapy today. Nursing health history is included in the database which could be a basis for providing appropriate interventions (Kozier and Erb,

2007). The purpose of the history is to develop data from which to make nursing assessments of all those taken into account when planning nursing interventions relative to the problem (Phaneuf, 1976). TOTAL 42
th

26

References: Kozier, B. And Erb, G. (2008). Kozier and Erbs Fundamentals of Nursing 8 ed. Pearson education South Asia Pte Ltd, Copyright 2008. Phaneuf, M. (1976). The Nursing Audit: Self-regulation in Nursing Practice 2nd ed. New York, Appleton, 1976. WHO (2013). International Classification of Diseases. Retrieved from http://www.who.int/classifications/icd/en/ Viljoen, M. (2005). General Nursing Medical and Surgical Textbook. Kagiso Tertiary copyright 2005. N.A (1994). Medical Records. Retrieved from http://www.med.navy.mil/directives/Documents/NAVMED%20P117%20(MANMED)/MMDChapter16.pdf