Leadership Case Study 3

Case Study # 3
You enter the room of Mrs. Smith to conduct your nursing history. While completing the physical assessment, you find her opioid patch on her upper back, but the nursing documentation from the previous shift indicates that it was removed about 1 hour ago. The conversation with Mrs. Smith reveals that the nurse taking care of her on the last shift started to remove the patch but got distracted and must have forgotten.

1. Quality nursing care depends upon accurate _______________________________ in the patient’s medical record.

You enter the room of Mrs. Smith to conduct your nursing history. While completing the physical assessment, you find her opioid patch on her upper back, but the nursing documentation from the previous shift indicates that it was removed about 1 hour ago. The conversation with Mrs. Smith reveals that the nurse taking care of her on the last shift started to remove the patch but got distracted and must have forgotten.

Adequate documentation is one of the best elements for defense vs.: 

Case Study
You enter the room of Mrs. Smith to conduct your nursing history. While completing the physical assessment, you find her opioid patch on her upper back, but the nursing documentation from the previous shift indicates that it was removed about 1 hour ago. The conversation with Mrs. Smith reveals that the nurse taking care of her on the last shift started to remove the patch but got distracted and must have forgotten.

Which of the following aspects of documentation are considered good quality? (Select all that apply.)

You enter the room of Mrs. Smith to conduct your nursing history. While completing the physical assessment, you find her opioid patch on her upper back, but the nursing documentation from the previous shift indicates that it was removed about 1 hour ago. The conversation with Mrs. Smith reveals that the nurse taking care of her on the last shift started to remove the patch but got distracted and must have forgotten.

You enter the room of Mrs. Smith to conduct your nursing history. While completing the physical assessment, you find her opioid patch on her upper back, but the nursing documentation from the previous shift indicates that it was removed about 1 hour ago. The conversation with Mrs. Smith reveals that the nurse taking care of her on the last shift started to remove the patch but got distracted and must have forgotten.


What should the nurse do with the opioid patch found on Mrs. Smith's upper back?

You enter the room of Mrs. Smith to conduct your nursing history. While completing the physical assessment, you find her opioid patch on her upper back, but the nursing documentation from the previous shift indicates that it was removed about 1 hour ago. The conversation with Mrs. Smith reveals that the nurse taking care of her on the last shift started to remove the patch but got distracted and must have forgotten.


What is the primary purpose of documenting the care provided to a patient?