Health information documentation needs proper management for the information to remain helpful. Health services greatly depend on these documented information. This dependence necessitates the documentation process to be accurate. The purpose of this essay is to describe the relationship between proper documentation and the five basic rights of drug administration, the legal and ethical issues surrounding the handling of medication errors, and the components of SOAP charting and the application of SOAP in a clinical scenario.
First, proper documentation helps physicians to implement the five basic rights of drug administration. These rights include the right patient, drug, dose, route, and time (Elliott & Liu, 2010). These documents help the medical professionals avoid identification-related errors. Thus, they help the medical professionals by providing correct information on the right patient required to receive a particular medication.
Additionally, the documents help some professionals such as nurses to avoid harming patients by administering the wrong medication dosage through wrong routes. Particularly, the physicians give these documents to the nurses after the completion of their ward rounds. The documents need to be correct since they provide the guidelines that the nurses will use when administering the drugs.
Moreover, proper documents help the nurses to timely administer the drugs to patients. According to Elliott and Liu (2010), this timely administration of medication helps to avoid issues such as wrong serum levels of the drug and low efficiency of the drug that result from bad timing. This can lead to an incorrect evaluation of the patients’ response to a particular drug. Thus, the professionals should correctly document the time intervals of the administration of a particular drug to avoid the resultant medication errors.
Furthermore, there are legal issues that result from the handling of these medication errors. Although the patients’ confidentiality is important, health institutions should report the cases of mistakes in the medication of patients and the resultant adverse effects (Mayo & Dunc, 2004). This step is necessary to help the authorities prevent reoccurrence of similar incidents. The act of institutions covering the incidents is unethical and can result in legal issues.
Precisely, the health institutions should only protect the information on the identity of the patients involved. Particularly, this is important if the errors have caused effects that might lead to the stigmatization of the patients (Cushman et al., 2010). The authorities will address the issues, but the patients will remain anonymous. Hence, this will prevent any further legal matters regarding the breach of the patients’ confidentiality.
SOAP is an acronym for Subjective, Objective, Assessment and Plan method of documentation. The health care providers use the approach when writing notes on patients’ chart. This approach is used greatly in the emergency and other hospital departments for record keeping and communication among the health care providers. For instance, the method can help in the scenarios of the pregnant lady. The subjective part will help the physician to get the patient’s history. The objective and the assessment part will then help the physician to examine and assess the patient respectively. Since Tagament is still safe for expectant ladies, the doctor can then advise the patient to continue using the drug as the physician’s plan.
Proper medical records are important to the success of health services. This is evident in the role that the documents play when observing the five fundamental rights of administering medication, addressing the legal, and ethical issues that result from improper records related errors. Additionally, documentation methods such as the SOAP method demonstrates the role that documentation play in ensuring the success of health services.
References
Cushman, R., Froomkin, A. M., Cava, A., Abril, P., & Goodman, K. W. (2010). Ethical, legal and social issues for personal health records and applications. Journal of Biomedical Informatics, 43(5), S51-S55. doi: 10.1016/j.jbi.2010.05.003.
Elliott, M., & Liu, Y. (2010). The nine rights of medication administration: an overview. British Journal of Nursing, 19(5), 300-307.
Mayo, A. M., & Duncan, D. (2004). Nurse perceptions of medication errors: What we need to know for patient safety. Journal of Nursing Care Quality, 19(3), 209-217.
