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Mandatory Reporting in Nursing Practice

Documentation and Mandatory Reporting

Mandatory reporting implies that nurses and other service providers are required to disclose an occurrence or an individual’s behavior that may put someone at risk. The study by Petschnig and Haslinger-Baumann (2017) reveals that reports can result in sustainable corrections in medical institutions and contribute to creating a safe hospital environment. Incidents records are crucial for patients’ safety as they allow to prevent adverse occurrences and medical mistakes (Fetherston, 2015).

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Documentation should include individual’s name and hospital number, date, time, and location of the occurrence, its factual description, information about the witnesses, details about the harm caused and action taken, and the name of the reporter.

The aspects of mandatory reporting in America are regulated by the National Council of State Boards of Nursing and may differ by state. The advantages of mandatory reporting include a decrease in future risks for patients and medical staff and the improvement of hospitals’ practices. The possible disadvantages are the challenges clinicians may encounter if their report is considered false. Moreover, in some cases, it can be difficult for them to provide full details about the incident or a person due to time pressure, fear, or uncertainty.

In this case, mandatory reporting is not performed correctly. The hypotensive episode was not disclosed to the registered nurse; vital signs also were not charted. Moreover, medical staff suspected Alcoff in alcohol abuse, which should have been reported as well. Medical professionals involved in the case lacked training, as they did not realize the significance of documenting adverse incidents. Reporting could have resulted in different health outcomes for the plaintiff.

Informed consent can be defined as authorization of an activity or a procedure based on the patient’s understanding of what it may result in (Grady, 2015). It underlines that a medical professional must disclose all information about the possible risks associated with treatment or, in this case, surgery, to the individual and discuss the likelihood that these will occur. For some types of interactions, including physical examination of a patient, informed consent is assumed; others require explicit consent. One of the significant components of informed consent is that it allows patients to have decision-making capacity.

It provides them with the ability to understand the options they have and assess the risks of the possible consequences for their wellbeing. Informed consent can present several challenges to the practitioners. For example, the scope and level of the information provided to patients are debatable (Grady, 2015). Moreover, physicians may encounter difficulties while applying communication strategies; these are crucial to individuals’ understanding of the risks and the benefits of medical activities. They should also ensure that they answer patients’ questions fully, providing the explanation in clear terminology and language.

In this case, the practitioner did not inform the patient that surgery could result in the fatal outcome and did not offer alternative procedures. Such practice does not correspond with clinicians’ duty to have professional competence as this case presents disrespect for patient’s autonomy (Blease, Lilienfeld, & Kelley, 2016). It is possible that medical professionals involved in the case were under the time pressure as the shift was busy. However, they should have ensured that the patient was aware of all aspects of surgery to avoid adverse outcomes and the following lawsuit.

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Preparation for Court

Murphy (2018) outlines significant issues regarding preparation for court for the involved parties. Clinicians that will receive a subpoena must not ignore it, as there are penalties for not complying with the order, even if medical professionals do not consider themselves guilty. The hospital staff responsible for the wrongful death should seek legal counsel’s assistance. This case will be reviewed by a civil court, which usually investigates the claims on medical malpractices.

When preparing for court, clinicians should carefully document the details of the case to present them (Murphy, 2018). They may also bring chart documentation and use it as a reference. Having handwritten notes is not recommended as they can be admitted to evidence; it may look suspicious to the court as well. Medical professionals should ensure that they know all of the details presented in the documentation, provide their curriculum vitae, and have a proper appearance in court. Witnesses must answer the questions without including additional information. If the question is unclear, it is crucial to ask to repeat or restate it. Finally, a friendly attitude can make a positive impact on juries.

The essential part of the preparation for court for all involved parties is a meeting with an attorney. A plaintiff can discuss their grievances and possible results of the trail. Defendants may consider reviewing their testimony with the attorney and discuss the dispute in the case. In this case, it may be significant for clinicians to have a meeting with both their attorney and the one that subpoenaed them to court to have a better understanding of their role in the trial. Medical professionals can also approach their colleagues who have been testified for malpractices to seek their advice.


Blease, C. R., Lilienfeld, S. O., & Kelley, J. M. (2016). Evidence-based practice and psychological treatments: The imperatives of informed consent. Frontiers in Psychology, 7. Web.

Fetherston, T. (2015). The importance of critical incident reporting – And how to do it. Community Eye Health, 28(90), 26-27.

Grady, C. (2015). Enduring and emerging challenges of informed consent. New England Journal of Medicine, 372(9), 855-862.

Murphy, J. L. (2018). When clinicians are summoned to testify in court: Orientation to the process and suggestions on preparation. SAGE Open Nursing, 4. Web.

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Petschnig, W., & Haslinger-Baumann, E. (2017). Critical Incident Reporting System (CIRS): A fundamental component of risk management in health care systems to enhance patient safety. Safety in Health, 3. Web.

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