Explain the content and function of the various types of clinical documentation entered by health care.
Explain the content and function of the various types of clinical documentation entered by health care.
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Recently a training was held by an outside organization for the care team at the skilled nursing facility in which you are the manager at. This training focused on the importance of documentation, and their motto was “if it wasn’t documented, it didn’t happen.” After the training was held, one of the medical assistants asked to speak with you. She related that a few days ago, one of the nurses gave a patient their insulin injection but didn’t document it in the chart. She stated that she asked the nurse if she would add that information in and was told to mind her own business. Later that evening, the new shift nurse noticed no injection was documented and gave one after the evening meal. The MA stated she kept an eye on the patient and noticed he was very agitated throughout the evening and had a difficult time going to sleep.
What would you do to handle this situation?
Please be sure to validate your opinions and ideas with citations and references in APA format.
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