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Who Should Sign?
The person who carries out the
treatment.
Thus even un-registered staff who
have first hand knowledge of events
may document.
Think Point
A part time nurse noticed that the heels of an 87
year old female resident were red and dry.
The nurse was not very familiar with the care
plan system. She handed her observation
over to the night nurse who told her not to
worry about the care plan.
The following morning the night nurse went on
annual leave for two weeks.
When the part-time nurse returned to duty 8
days later the resident had developed a
gangrenous heel and was in pain.
Think Point
Is there a case for negligence here?
Who is responsible?
Legally a case could be taken stating
that the patient suffered “foreseeable
harm”.
Think about your own written records of
care, does your documentation give
enough information to justify your
actions, omissions and decisions?
Protection
Nurses must guard against liability by
keeping up-to-date on every aspect of their
practice, identifying risk factors associated
with documentation, implementing risk factors
associated with documentation, implementing
risk-reduction practices and following these
practices until they become second nature.
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Appendices