The Purpose Of Medical Records In The Analysis Of Nursing Negligence Free Essay

This paper will explain the purposes of the medical record and nursing’s responsibility and define a vulnerable patient as well as analyze a case of medical negligence.


Those responsible for the well-being and survival of human beings should exercise greater responsibility. It is no doubt that life is sacred and should therefore be protected. It is for this reason that the Joint Commission for Accreditation of Healthcare Organizations has come up with the best practice for medical records and nursing’s responsibility. In doing so, there is a need to have a clear understanding of who qualifies to be considered a vulnerable patient. This will help medical practitioners not to be sued for negligence. This paper will explain the purposes of the medical record and nursing’s responsibility and define a vulnerable patient as well as analyze a case of medical negligence.

After close observation and research, it was established that the majority of medical errors are associated with a lack of adequate or proper communication. Lack of communication was established to be the major reason for infection, re-infection and even death to patients. This has resulted in scenarios where the affected individuals brought lawsuits against individuals in the medical fraternity. It is no doubt that some cases were found to have no legal grounds while those found to be serious led to serious consequences on the side of nurses and doctors. Since effective communication generally increases the quality of service, supports teamwork and more importantly help individuals and authorities in preventing errors, it is important for healthcare providers to adopt it. It is thus the responsibility of the Joint Commission for Accreditation of Healthcare Organizations to ensure that healthcare facilities adopt best practices in keeping records in order to enhance effective communication which in the long run brings the aforementioned advantages.

In order to ensure that those involved in healthcare provision do effective documentation, there are a number of concepts that should be adhered to. These concepts are; recording factual information, recording accurate information that is complete, current, organized and in compliant with the set standards.

The issue of vulnerable patients is an important concept that healthcare providers should focus on. There are a number of groups considered as vulnerable patients. They include young children, older population, mentally ill, individuals in lower economic level, individuals having communication problems. Young children in most cases suffer from extreme anxiety, older people need extra care since they are physically and mentally impaired, individuals in lower economic bracket in some cases cannot afford the best medical care while those from different languages may miss to communicate effectively.

In the case of Ms. Fosby it is evident that she has a valid case against the defendant hospital. It is evident that nurses and other medical practitioners are obliged to provide their patients with accurate and truthful information. After evaluating the report of the pin , the hospital failed to provide Ms. Fosby with the relevant information. This goes against her notion that medical practitioners should practice without deception. Failure to provide the patient with the information she needed amounts to negligence. This has a negative impact to the patient since she is living in anxiety. If I was to decide on this case, I will hold the hospital accountable for not sharing relevant information that would help the patient overcome anxiety of having contracted HIV. Despite the fact that the hospital went ahead and tested the patient thrice, failure by the hospital to provide the patient with a full report left her confused and mentally disturbed.

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