For example, while doing my inventory of medications during a night shift for a palliative patient, I figured out that one of the medications of the patient which should be given every other day is insufficient in number based on the baseline inventory of medications. So, I recounted the stocks of medications well and also checked the medication box and supplies again but unfortunately the inventory was still insufficient. So what I did next was to check the medication sheet on the patient’s chart and I found out that it was given earlier that night. I wondered why it was given, hence I checked the doctor’s order if there were any changes with the medication administration, but there was none. I then …show more content…
(C. #85) (C. #32) After notifying the physician, I monitored the patient closely for any untoward signs and symptoms or side effects of the medication. (C. 113c) Afterwards, I documented in patient’s chart all the nursing care given and also, I made an incident report where I stated every detail of what had happened, actions taken and nursing care given and of course the client’s response as well. (C.#113d) (C.#113a – Accountability) Moreover, “Nursing documentation is an important component of nursing practice and the interprofessional documentation that occurs within the client health record. Documentation—whether paper, electronic, audio or visual—is used to monitor a client’s progress and communicate with other care providers. It also reflects the nursing care that is provided to a client.” (College of Nurses of Ontario, 2009, p. 3) (C.