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Melanie looked up at the clock - 11am. "Wow," she thought, "It's been

a busy day and I am not even halfway through yet!" After 5 years in this Extended Care Unit, she had got used to being busy, but today seemed to be 'one of those days'. She was, as usual, the only RN on today in this 36 bed unit, along with one LPN and four Registered Care Aides. She knew that everyone would be busy: The unit was full and the current client group required a lot of care - and that made for a heavy workload for everyone.
She paused for a moment to collect her thoughts and decide on the next thing she needed to do. While her responsibility encompassed all of the clients on the unit, there were four clients that particularly concerned her today. Two were confused and agitated and required close monitoring, another was dying and, with his family at his bedside, needed comfort care and support, and finally Mr Bell had been short of breath and coughing during the night. When Melanie had looked in on him earlier he was breathing at 24/ minute, occasionally coughed up yellowish secretions and had a temperature of 37.6C.
Her thoughts were interrupted when Jasmine, an LPN who had worked on the unit for 10 years, stopped beside her and said, "Can you come and look at Mr. Bell? He seems to be worse that he was earlier this morning. I sat him up a bit more and that helped a little, but I am quite concerned about him." Melanie nodded and they walked down the hallway to Mr. Bell's room. At first glance it was clear to Melanie that he was worse. His face was slightly diaphoretic and she could hear his coarse cough. When she asked him how he was feeling, he replied, "I feel pretty tired. This coughing is wearing me out."
She nodded and said, "I can see that. If it's OK with you, I would like to have a closer look at you." She counted his respiratory rate at 26/minute and then had a quick listen to his chest. She noted that he had coarse crackles in both posterior and anterior lower lung fields. His temperature was 37.7C.
Melanie bent slightly closer to him and spoke gently. "Mr. Bell, I can see that you are not feeling well and that you are tired. Your chest sounds kind of rattly and you have a bit of a fever. I am going to call your family doctor and let him know. I'll come back as soon as I have done that and let you know what he says."
Melanie called Dr Simms and explained the situation, outlining the change in Mr. Bell's condition over the previous 24 hours. In response, Dr Simms suggested that Mr. Bell "probably has the flu that's going around" and instructed Melanie to "keep an eye on him" and to "call him back if she was concerned".
Melanie hung up the phone and pulled Mr. Bell's chart from the shelf. She made the following entry in his nursing notes:

"Client seems short of breath. Has a fever. Doctor informed."

Melanie returned to Mr Bell and, as per the unit's standing orders, gave him some Tylenol elixir "for comfort". She also made sure he was well positioned in bed and then left the room to continue with her care for other clients. Over the next four hours, she checked in on Mr Bell several times and counted his respiratory rate, noting that it was still high. At one point she listened to his chest again, noticing that the crackles had increased. Four hours after her initial phone call, Melanie was quite concerned about Mr Bell - His respiratory rate was 30/minute, he seemed to be working harder with his breathing, his chest sounded worse, and his pulse oximeter read 92%. She knew that often when clients were sick like this, that they would be send the client to ER at the local hospital, however, Dr Simms had indicated he was happy to be called about his clients, so she decided to call him again and update him. After she had explained the situation, Dr Simms said "I am leaving my office shortly and have to drive past the care facility on my way home, so I will drop in and have a look at Mr Bell."
Melanie reached hung up the phone, glanced at the clock and realized she has several medications that she was late dispensing. She quickly wrote a note in Mr Bell's chart, and then left the office area to attend to the medications.

Client's breathing looks worse. Doctor notified.

Dr Simms arrived 45 minutes later and assessed Mr Bell. He then wrote an order to start Mr. Bell on antibiotics and to begin supplemental oxygen via nasal prongs at 3L/minute. Melanie came into the office as he had just completed writing the orders. "Oh Hi, you're here," she said. "What do you think is happening?" she asked.
He replied, "I think he has the flu, and seems to have a bit of chest infection. I have ordered him some antibiotics and we can start some oxygen therapy and see if that makes him more comfortable. Can you check his pulse oximeter readings every two hours. If they fall below 92%, or if you think he is getting worse, please call an ambulance and send him to the ER."
As Dr Simms left, Melanie reviewed the orders he had written and faxed the prescription for antibiotics to the pharmacy. She also updated the documentation in Mr Bell's chart:

Dr in. Orders received.

1.   Review Melanie's documentation. In what ways does it meet criteria for effective documentation? What documentation errors are present? Where there are errors, describe how Melanie should have documented Mr. Bell's care in these situations. Provide examples of effective documentation.

2.   What factors do you think influenced Melanie's ability to document appropriately in this situation? What do you think could be done that would assist Melanie to document effectively in future

3.   What are the implications of Melanie's ineffective documentation for Mr Bell's outcomes?

4.   Consider the conceptual framework and directives for documentation in nursing practice. What could be the implications of Melanie's ineffective documentation for herself?

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