He enters his assessment into Mr. Berge’s electronic medical record (EMR) and sends an electronic request for a wound care consult.
Sara, the wound care clinician, assesses Mr. Berge and his wound, makes a diagnosis and determines the wound care that would be most appropriate at this time. She enters a client-specific order in the EMR, for the wound to be dressed with a specific product once/day.
Sara is accountable for her clinical decision-making supporting the client-specific order she has given and evaluating the outcome of the treatment on Mr. Berge’s wound. She’s also accountable for following her organization’s policy and processes to ensure continuity of care for Mr. Berge, including answering questions about the ordered treatment, evaluating the outcome and amending the order if required.
In this situation, both the Standards for Acting within Autonomous Scope of Practice and Giving Client-specific Orders apply.
Acting with the client-specific order, Jess provides wound care to Mr. Berge. Over the next two days, he assesses Mr. Berge’s wound, determines the ordered activity is still appropriate and dresses the wound.
When he removes the dressing early Saturday evening however, Jess sees signs of infection. He notes the wound is larger by 2mm, reddened at edges and appears to contain some exudate. Mr. Berge also reports pain around the area.
Before acting on the client-specific order for Mr. Berge’s wound care, Jess is accountable for making sure the activity is within his scope of practice and individual competence. He must have the competence to:
The Standards for Acting with Client-specific Orders apply in this situation.
Jess knows that the dressing type ordered is contraindicated with infected wounds. Knowing that the wound care clinician is not available to reassess Mr. Berge's wound until Monday, he consults with the clinical leader, Preeti. Together they decide on the appropriate action, including a different dressing. Preeti explains why the new dressing is more appropriate for this wound.
Preeti logs in to Mr. Berge’s EMR and cancels the client-specific order. She enters a new order, substituting the more appropriate dressing product, and updating the plan of care. She also sends a new request for a wound care consult.
Jess cleans the wound and takes a swab for C&S. He then redresses it, substituting the different product. He documents his assessment, conclusion and actions in Mr. Berge’s EMR. At handover, Jess lets the oncoming staff know which client-specific order has been cancelled, that a new order is in place, and that a new wound care consult has been requested.
What is Jess accountable for?
Jess is accountable for his clinical decision-making supporting his assessment of Mr. Berge’s wound, following organizational policy and taking appropriate action. This includes communicating and collaborating with the ordering wound care clinician (or their delegate), and the health care team when the ordered wound care is no longer appropriate because the condition of Mr. Berge’s wound has changed.
In this situation, Jess follows the Standards for Acting with Client-specific Orders.
If Sara, the wound care clinician who gave the order, is not available, organizational policy should outline responsibilities and processes for ensuring continuity of care for Mr. Berge’s wound.
What is Preeti accountable for?
When Preeti makes the decision to cancel the client-specific order and give a new one, she is acting within her autonomous scope of practice and assumes sole accountability for her decisions and actions. She’s accountable for her clinical decision-making supporting the client-specific order she has given and evaluating the outcome of the treatment on Mr. Berge’s wound, until the wound care clinician is able to reassess.
Both the Standards for Acting within Autonomous Scope of Practice and Giving Client-specific Orders apply in this situation.
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