Critical Thinking: Reflective Case Study 

Mr. Reyes is a 72-year-old patient with a diagnosis of Multiple Myeloma,ongoing

treatment of chemotherapy, hypertension, diabetes mellitus, chronic pain,
alcoholism, and clinical depression. He was admitted due to fever ,cough and low
level of platelet count. Nurse Ana is the registered nurse assigned to the day shift
care of Mr. Reyes, as well as five other patients on the unit. During morning shift
change, she received report that Mr. Reyes was "non-compliant" with his
medications and was not able to sleep throughout the night , refusing to take his
food and medicines .

During her rounds Nurse Ana noted Mr Reyes negative verbal output while trying
to convince him to take his food and medication. Three hours later Nurse Ana
returned to Mr Reyes room and explained the importance of taking food and
medication which will worsen his condition. Nurse Ana informed Mr Reyes
attending physician about the present condition of Mr Reyes.  During Ana’s duty
another patient on Ana’s schedule became acutely ill, and Ana’s attention was
diverted from Mr. Reyes for the next few hours. Ana finally connected with Mr.
Reyes physician later in the day and ordered referral to Nuerologist for proper
assessment of depression. Ana endorsed Mr Reyes to the incoming shift and when
She got home Ana realized that She was not able to document the problems She
encountered with Mr Reyes and forgot to write in the Doctor’s order sheet about the
need of the referral to neurologist.

Identify the problems surrounding Ana's nursing documentation and describe

ways in which Ana rendered herself and her employer liable for a malpractice
lawsuit. Provide examples of how her documentation could be improved.