Monday, October 5, 2009

Nurse fails to document alleged assault?


Further retort to a senior HRM manager who has refused to investigate an apparent serious lack of legally required nursing documentation . . .
A nurse in charge of their shift recently reported another nurse for (allegedly), assaulting a patient - but from all obvious appearances, completely failed to document the alleged assault in the patient's medical chart. However, the senior HRM manager who has been asked to investigate this (apparently), serious failure to provide a legally required record, has refused to do so - and has referred the complainant back to the same nurse managers who supervised and enabled the ommission in the first place.
In a nutshell, if a nurse witnesses another nurse assaulting a patient, they have a legal duty to document their observations in the patient's medical chart. This is for the protection of the patient, the protection of the nurse witnessing the alleged assault, and the the protection of the accused nurse. It provides formal and indelible evidence, to which all parties can refer.
If I (or any other nurse), are ever accused of assaulting a patient by the nurse in charge of the shift (or by any other nurse colleague on shift for that matter), I would insist they formally document their recollection of events in the patient's medical chart there and then. That documentation can then (transparently), be compared to a doctor's timely physical examination, and remains a part of the public record for any and all further court proceedings.
Further, here are the Queensland Nursing Council standards for nurse documentation:
So, HRM manager, please get back to me by the end of the week to tell me if you are willing (or otherwise), to formally investigate this matter. If not, I'll report it to the Queensland Nursing Council, and inform them that I reported it to you first, but that I'm passing it on to them, because you failed to act.

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