Verbal Order In Nursing Care Essay

Next, the undocumented verbal order is also another area of concern in relation to documentation (Williams & Wilkins, 2007). A verbal order is medical orders from the physician when the physician is communicating verbally by telephone about the patient’s management especially with the nurses in charge. This might happen for example when the doctors are not available in the ward to submit written orders but the continuity of care is urgently needed. When the nurse encounter this kind of situation, the nurse who is taking verbal order should document the order, physician’s name, as well as the date and time the order was taken. In a hospital setting, the nurse needs to ensure that verbal order should be signed by the physician within 24 hours.

Accidental needle stick injuries (NSIs) are the most common incidents occur in the wards. This incident may result in actual injury to the patients, nurses or other health care professionals. The Occupational Health Unit in the Ministry of Health, Malaysia, (2005) reports an incidence rate of 4.7 needle stick injuries per 1,000 health care workers. A hospital-based cross-sectional study conducted by Bhardwajet et al., (2014) in orthopedic wards Melaka General Hospital reported that the prevalence of NSIs was high in operation theatre involving specialist (n= 6, 18.8%), medical officer, (n=12, 37.5%), house officer (n=10, 31.2%) and staff nurses (n=4, 12.5%). In relation to needle prick injury, nurses are responsible for preparing a complete and comprehensive incidents report in which they are involved. However, for legal reasons, the incidents report should not be attached to the nursing chart. The incident report acts as an internal device for the health care

The College of Nurses of Ontario (CNO) (2008) stated that there are eight standards of documentation. The first one is client-focused. It explains that the documentation should be about the client and this includes the extension of his or her family or someone who is legally named if there is no family. Next is about relevant. Any charting or reporting of any event should be relevant to a particular client’s care and progress. Confidential is also one of the important parts in standards of documentation whereby the client’s information should not be revealed out. The subsequent characteristic of standards documentation is 3C’s which stand for clear, concise, and comprehensive. These 3C explain about the accuracy of information documented. Next, the information should be permanent and retrievable. Therefore, it is advisable for nurses to use black ink during the process of documentation. Nurses need to remember that client notes become a permanent and retrievable health record. These could be retrieved several months or years later by a lawyer for examination. The sixth is about accuracy. One of the most common deficiencies in documentation is the accuracy of missing details. Lack of significant detail is also the most highly criticized in the legal process. During documentation process, nurses need to clearly know how to differentiate between significant