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DOCUMENTATION ERROR FOR FORGOTTEN DJ STENT IN PYELOLITHOTOMY

Sumara Rehman, Sana Sehar, FoziaAfzal, Muhammad Afzal, Pro. M Amir Gilani

A 40 year old patient admitted in neurology unit for Pyelolithotomy, after surgery the dr. forgets to document the presence of stent in kidney and its removal. After discharge the patient came with complaint of high grade fever and severe pain. After investigating it was diagnosed that stent was present in the kidney. When inquire about this the patient refuse to accept its presence and on discharge card it also missed. Results The outcomes of this documentation error highly effect to the patient, to health care team and health institute. Decision making theory applied to solve this issue. Discussion According to literature review the researcher said that documentation is a most important part of nursing duties. Proper documentation minimizes problems and save record. Online system should be used for documentation record. Key words: documentation error, documentation and advance technology, forgotten DJ stent, Pyelolithotomy

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