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Source: Health and Disability Commissioner

The importance of adequately documenting assessments and treatment plans was highlighted in a decision published by Deputy Health and Disability Commissioner Dr Vanessa Caldwell.
In her decision, Dr Caldwell found two nurses in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to comply with the Nursing Council of New Zealand (NCNZ) Code of Conduct for Nurses, and prison service policies for clinical documentation.
This case concerns care provided to a man who was found unresponsive in his cell. He was assessed by a nurse, and the recorded plan was to refer the man to hospital for follow-up. However, there were significant omissions in the documentation of the nurse’s assessment, making it difficult to determine the adequacy of the assessment. There was no evidence of a physical assessment of his head, including looking for any lacerations, bruising, or swelling to the face or scalp, to determine whether there had been any trauma to the head.
Failure to undertake these assessments represented a severe departure from accepted practice, particularly when the purpose of the assessment was to determine how the man became unresponsive.
Prison officers were also asked to continue observation of the man until his transfer to hospital, but records of any observations made could not be located by the prison service.
Another nurse reviewed the man later that day, and similarly there were omissions and inaccuracies in the documentation of care provided, including failing to provide any evidence for making a change in diagnosis from a possible concussion to a gastric issue and deciding not to send the man to hospital. These omissions represented severe departures from accepted practice, and made it very difficult to understand the patient’s clinical situation and the rationale for the treatment decisions being made.
The next day, a GP who subsequently examined the man determined his earlier loss of consciousness required further investigation, including a chest x-ray and referral to a specialist.
In her decision, Dr Caldwell was critical of both nurses for omissions in documentation of their assessments of the man. Prison service policies state documentation in a clinical emergency response should include all clinical information and actions taken. The NCNZ Code of Conduct for Nurses states nurses should keep clear and accurate records of any discussions and assessments made. In addition, nurses should ensure entries in a patient’s clinical records are clearly and legibly signed, dated, and timed. The prison service’s Health Care Policy also provides the standard for documentation, and requires that documentation is dated, accurate, and relevant.
Dr Caldwell says, “I am critical of multiple omissions in the documentation, and that staff did not adhere to the documentation requirements of the prison service’s policies. Documentation should be accurate and comprehensive to ensure staff have all relevant information following handovers”.
The prison service has a responsibility to operate its health service in a manner that provides consumers with services of an appropriate standard.
“While I have some concerns about the care provided to the man, I do not consider the prison service breached the Code. However, I am concerned about multiple omissions in the documentation of the care provided to the man by different staff on different occasions, and the prison service’s failure to locate any record of observations made by officers. I consider that this reflects poorly on the prison service’s record-keeping systems at the time of the events,” says Dr Caldwell.
Dr Caldwell made several recommendations, including that the nurses both undertake training on documentation, and provide a written apology to the man. She also recommended the prison service provide evidence that nursing staff have received training on documentation standards and relevant healthcare policies, and that it consider the adequacy of guidance and training currently provided to officers in relation to the observation of patients with health conditions.
“I acknowledge the substantial changes made by the prison service since these events to improve the training provided to staff, which will improve the standard of documentation.
“I encourage the prison service to continue its work in this area, and ensure staff have the training and tools necessary for accurate and complete documentation,” says Dr Caldwell.
The Commissioner will usually name providers found in breach of the Code, unless it would not be in the public interest, or would unfairly compromise the privacy interests of an individual provider or a consumer.