patient’s health status. This documentation is an important tool for communication among healthcare professionals and a legal record of the care provided. This paper will focus on the analyses of the impact of documentation and lack thereof in the healthcare sector. Additionally, the paper will address the issue of professional liability insurance policies and how they are applied in fields and instances.

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Nursing Documentation and Professional Liability Insurance

Nursing documentation is the record of a nurse’s observations, assessments, interventions, and evaluations of a patient’s health status. This documentation is an important tool for communication among healthcare professionals and a legal record of the care provided. This paper will focus on the analyses of the impact of documentation and lack thereof in the healthcare sector. Additionally, the paper will address the issue of professional liability insurance policies and how they are applied in fields and instances.

Case One: Chapter Ten

Did the lack of documentation in the admitting nurse’s assessment and notes affect the ultimate outcome of this case?

As a physician, I believe that the lack of documentation pertaining to the overall grade III necrotic pressure ulcer on the coccyx for the patient as well as any other specialized treatment may have played a role in the patient’s ultimate outcome. From one perspective, it could be considered a case of delayed diagnosis due to the failure of the nurse to identify the symptoms (Guido, 2020).

Furthermore, the competency of the nursing staff at home is questionable. It is likely that their insufficient expertise contributed to the failure to identify the issue at the assessment level the need for better bedding. The main concern is whether the nursing home has any established protocols for the care of bedridden patients and if they provide appropriate bedding for treatment and prevention measures. In this instance, the risk for developing pressure ulcers ought to have been noticed at an earlier stage, highlighting the importance of utilizing specialized mattresses.

However, it could also be argued that if a diagnosis had been made and documentation had been properly kept, it could have directly impacted the patient’s final outcome. Early administration of the correct treatment by other members of the healthcare team could have potentially altered the patient’s outcome.

Was there negligence on the part of the nursing staff in the care of this patient?

The patient’s death can be attributed to the neglect of the nursing staff, which constitutes a violating the standards of nursing. The failure to properly observe the progress of the patient within the nursing facility is a clear indication of negligence. Care providers are trained and expected to assist their assigned patients through constant and effective evaluating them and consistently recording any changes in their condition (Griffith, 2020). The patient’s outcome was negatively affected due to the nursing team’s failure to assess and diagnose pressure ulcers properly.

The inadequate quality of treatment and documentation further supports the conclusion of negligence. There is no evidence of supported ambulation or the use of specialized mattresses in the patient’s medical records, indicating a lack of adherence to established standards of care. I believe that the nursing staff who provided care for this patient neglected their duties by failing to properly document procedures, thereby committing negligence.

What could the nurse have done differently to facilitate a different outcome in this case?

The outcome for this patient could have been different if the nurse had paid more attention to the risk factors for pressure ulcers among all patients in the institution. Patients in intensive care who are unable to move or walk are at a higher risk of developing pressure ulcers (Konetzka et al., 2018). Had the nurse discovered the susceptibility of the patient to pressure ulcers, she could have recommended different interventions, such as the use of particular mattresses to prevent their development.

Essentially, the nurse should have conducted a thorough examination of the patient upon admission and during their stay to identify pressure ulcer risks or even to identify pressure ulcers that had already developed. By taking such action in a timely manner, the nurse identified the key issues leading to proper documentation and communication with the relevant personnel. The immune system of the patient was already weakened, making it more likely that other conditions would have developed if the pressure ulcer had been treated sooner.

How would you decide this case?

Based on the case study, the case can be concluded that the care facility’s services were negligent. My decision on the case is based on the failure to properly examine the patient to detect the presence of a pressure ulcer and the potential for such an injury to occur over an extended period (


Case One: Chapter Ten

Did the lack of documentation in the admitting nurse’s assessment and notes affect the ultimate outcome of this case?

As a physician, I believe that the lack of documentation pertaining to the overall grade III necrotic pressure ulcer on the coccyx for the patient as well as any other specialized treatment may have played a role in the patient’s ultimate outcome. From one perspective, it could be considered a case of delayed diagnosis due to the failure of the nurse to identify the symptoms (Guido, 2020).

Furthermore, the competency of the nursing staff at home is questionable. It is likely that their insufficient expertise contributed to the failure to identify the issue at the assessment level the need for better bedding. The main concern is whether the nursing home has any established protocols for the care of bedridden patients and if they provide appropriate bedding for treatment and prevention measures. In this instance, the risk for developing pressure ulcers ought to have been noticed at an earlier stage, highlighting the importance of utilizing specialized mattresses.

However, it could also be argued that if a diagnosis had been made and documentation had been properly kept, it could have directly impacted the patient’s final outcome. Early administration of the correct treatment by other members of the healthcare team could have potentially altered the patient’s outcome.

Was there negligence on the part of the nursing staff in the care of this patient?

The patient’s death can be attributed to the neglect of the nursing staff, which constitutes a violating the standards of nursing. The failure to properly observe the progress of the patient within the nursing facility is a clear indication of negligence. Care providers are trained and expected to assist their assigned patients through constant and effective evaluating them and consistently recording any changes in their condition (Griffith, 2020). The patient’s outcome was negatively affected due to the nursing team’s failure to assess and diagnose pressure ulcers properly.

The inadequate quality of treatment and documentation further supports the conclusion of negligence. There is no evidence of supported ambulation or the use of specialized mattresses in the patient’s medical records, indicating a lack of adherence to established standards of care. I believe that the nursing staff who provided care for this patient neglected their duties by failing to properly document procedures, thereby committing negligence.

What could the nurse have done differently to facilitate a different outcome in this case?

The outcome for this patient could have been different if the nurse had paid more attention to the risk factors for pressure ulcers among all patients in the institution. Patients in intensive care who are unable to move or walk are at a higher risk of developing pressure ulcers (Konetzka et al., 2018). Had the nurse discovered the susceptibility of the patient to pressure ulcers, she could have recommended different interventions, such as the use of particular mattresses to prevent their development.

Essentially, the nurse should have conducted a thorough examination of the patient upon admission and during their stay to identify pressure ulcer risks or even to identify pressure ulcers that had already developed. By taking such action in a timely manner, the nurse identified the key issues leading to proper documentation and communication with the relevant personnel. The immune system of the patient was already weakened, making it more likely that other conditions would have developed if the pressure ulcer had been treated sooner.

How would you decide this case?

Based on the case study, the case can be concluded that the care facility’s services were negligent. My decision on the case is based on the failure to properly examine the patient to detect the presence of a pressure ulcer and the potential for such an injury to occur over an extended period (Griffith, 2020). Additionally, the lack of documentation suggesting the patient had been using pressure-relieving mattresses to prevent and treat pressure ulcers, and the absence of established protocols for caring for older, bedridden patients would further support this claim


Nursing Documentation and Professional Liability Insurance

Nursing documentation is the record of a nurse’s observations, assessments, interventions, and evaluations of a patient’s health status. This documentation is an important tool for communication among healthcare professionals and a legal record of the care provided. This paper will focus on the analyses of the impact of documentation and lack thereof in the healthcare sector. Additionally, the paper will address the issue of professional liability insurance policies and how they are applied in fields and instances.

Case One: Chapter Ten

Did the lack of documentation in the admitting nurse’s assessment and notes affect the ultimate outcome of this case?

As a physician, I believe that the lack of documentation pertaining to the overall grade III necrotic pressure ulcer on the coccyx for the patient as well as any other specialized treatment may have played a role in the patient’s ultimate outcome. From one perspective, it could be considered a case of delayed diagnosis due to the failure of the nurse to identify the symptoms (Guido, 2020).

Furthermore, the competency of the nursing staff at home is questionable. It is likely that their insufficient expertise contributed to the failure to identify the issue at the assessment level the need for better bedding. The main concern is whether the nursing home has any established protocols for the care of bedridden patients and if they provide appropriate bedding for treatment and prevention measures. In this instance, the risk for developing pressure ulcers ought to have been noticed at an earlier stage, highlighting the importance of utilizing specialized mattresses.

However, it could also be argued that if a diagnosis had been made and documentation had been properly kept, it could have directly impacted the patient’s final outcome. Early administration of the correct treatment by other members of the healthcare team could have potentially altered the patient’s outcome.

Was there negligence on the part of the nursing staff in the care of this patient?

The patient’s death can be attributed to the neglect of the nursing staff, which constitutes a violating the standards of nursing. The failure to properly observe the progress of the patient within the nursing facility is a clear indication of negligence. Care providers are trained and expected to assist their assigned patients through constant and effective evaluating them and consistently recording any changes in their condition (Griffith, 2020). The patient’s outcome was negatively affected due to the nursing team’s failure to assess and diagnose pressure ulcers properly.

The inadequate quality of treatment and documentation further supports the conclusion of negligence. There is no evidence of supported ambulation or the use of specialized mattresses in the patient’s medical records, indicating a lack of adherence to established standards of care. I believe that the nursing staff who provided care for this patient neglected their duties by failing to properly document procedures, thereby committing negligence.

What could the nurse have done differently to facilitate a different outcome in this case?

The outcome for this patient could have been different if the nurse had paid more attention to the risk factors for pressure ulcers among all patients in the institution. Patients in intensive care who are unable to move or walk are at a higher risk of developing pressure ulcers (Konetzka et al., 2018). Had the nurse discovered the susceptibility of the patient to pressure ulcers, she could have recommended different interventions, such as the use of particular mattresses to prevent their development.

Essentially, the nurse should have conducted a thorough examination of the patient upon admission and during their stay to identify pressure ulcer risks or even to identify pressure ulcers that had already developed. By taking such action in a timely manner, the nurse identified the key issues leading to proper documentation and communication with the relevant personnel. The immune system of the patient was already weakened, making it more likely that other conditions would have developed if the pressure ulcer had been treated sooner.

How would you decide this case?

Based on the case study, the case can be concluded that the care facility’s services were negligent. My decision on the case is based on the failure to properly examine the patient to detect the presence of a pressure ulcer and the potential for such an injury to occur over an extended period (


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