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Quite a few years ago, our hospital required all
nurses to attend a class on documentation given by our
hospital risk management and quality assurance departments.
They stressed complete and accurate documentation, giving
examples of good and bad charting.
One statement
mentioned in that class
has improved my practice….
“In a court of law, how would you explain your
practice?”
As nurses, we
are patient advocates, their voice, their representatives,
their care-givers. We
know our own strengths and weaknesses. It is our
responsibility to make sure we attend in-services on new
equipment that we will be responsible for running, that we
are current in ACLS, that we keep ourselves updated on
proper procedures, policies and protocols, learn from our
own and others experiences, share what we have learned …in
short…be the best we can be at what we do. (Put ourselves
in the patients shoes. Would you want the nurse you are to
be taking care of you?)
If we question
ourselves, when caring for these patients, as if we had to
explain our actions in a court of law, our practices would
be much improved. One
example I gave a new OR nurse recently was
“When having a
patient transfer from a stretcher to the OR table,
make sure of four things. That the OR bed is locked - that
the stretcher brake is on - that you stay on the stretcher
side of the patient to hold the stretcher – that there is
some one else on the other side of the OR bed to
receive the patient. I have seen OR tables left unlocked,
stretchers with brakes on that slide and we never want
a patient moving onto the OR table with no one on the other
side to receive them.”
Ask yourself, if this patient fell between the
stretcher and OR table or fell off the other side of
the table, besides harming a patient entrusted to your care,
in a court of law, how would you explain the
fact that you did not make sure the OR table was locked,
support the stretcher or have someone else on the other side
of the table to receive the patient?
Lorraine
Heslop RN, CNOR
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