Registered Health Information Administrator
Question No. 1
Case Study #1
Dr. Roberts, an orthopedic surgeon, and Nurse Parrish head nurse on the orthopedic surgery unit, have had an acrimonious working relationship for years. While making rounds on the unit, Dr. Roberts discovered that the physical therapy evaluation he has ordered for one of his patients had not been performed and became outraged. Even though he did not have proof, Dr. Roberts placed the blame for missed evaluation with Nurse Parresh. Dr. Roberts wrote in the patient’s medical record that Nurse Parrish frilled to properly order the physical therapy evaluation because she was incompetent and could not be trusted to carry out even the simplest order. After heaving read Dr. Roberts note, Nurse Parrish countered by making a disparaging remark about Dr. Roberts to the medical personnel at the nurces’ station. Nurse Parrish stated that Dr. Roberts was one who was incompetent and was responsible for the needless suffering of countless patients over the years.
Referring to Case Study #1, the written statement by Dr. Roberts about Nurse Parrish's professional competence in the patient's medical record can constitute