A nurse is reviewing a client’s medical record and notices that there is no documentation of informed consent for a surgical procedure that was performed earlier that day. Which action should the nurse take?
A.
Report the incident to the risk management department.
B.
Document the incident in the client’s medical record.
C.
Contact the health care provider who performed the procedure.
D.
Notify the client’s family members of the incident.
If a nurse discovers that there is no documentation of informed consent for a surgical procedure that was performed, the priority action is to address the potential legal and ethical implications. Here’s a breakdown of the options:
- A. Report the incident to the risk management department: This is the most appropriate action. The risk management department can assess the situation, address potential legal risks, and help ensure that proper procedures are followed to mitigate any adverse consequences. This department is responsible for handling situations that could lead to legal action or impact patient safety.
- B. Document the incident in the client’s medical record: While it is important to document incidents in the medical record, it is not the first step in addressing the issue of missing informed consent. The lack of documentation should be reported to the appropriate department for further investigation.
- C. Contact the health care provider who performed the procedure: Contacting the provider might be necessary to gather information about the consent process, but it does not address the immediate need for reporting the lack of documentation.
- D. Notify the client’s family members of the incident: Notifying the family may be appropriate in certain circumstances, but the primary concern is to report the missing documentation to the risk management department, which will handle further actions, including communication with the family if necessary.
Correct Answer: A. Report the incident to the risk management department.
The risk management department will handle the situation appropriately, including investigating the missing documentation, assessing any potential risks, and ensuring that all necessary steps are taken to address the issue and prevent future occurrences.