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HUCL1301 Fundamental Or Medical Order

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HUCL1301 Fundamental Or Medical Order All health care professionals have a scope of practice that they must operate within. A scope of practice can be defined as “the parameters of duties and responsibilities outlined by one’s professional training and skill set” – (V. Thompson, 2014).   In health care there are regulated professions and unregulated professions. A regulated profession requires one to have special education, practical experience and to be licensed by a regulatory body such as the College & Association of Register Nurses of Alberta. Each regulatory body has their own requirements one must meet in order to earn and maintain a license. Some examples of regulated professions that you will be working with as an HUC include; Physician’s, RN’s, and LPN’s. An unregulated profession typically require some education and training, however does not require to be licensed by a regulatory body. Some unregulated professions can have associations that will outline a standard of practice for those working within that profession, i.e. The National Association of Health Unit Clerks/Coordinators. Examples of unregulated health professionals that you will be working with as an HUC include; other HUC’s, Health Care Aides, Nursing Attendants, and Health Service Aides.     As professionals, it is imperative that we know the boundaries of our scope of practice and that we stay within those boundaries. Having these limits in place not only protects our clients but gives them confidence that the person looking after them is qualified to do so. One way that we can accomplish this is through proper medical documentation as this helps establish and maintain professional responsibility and accountability. As discussed in Module 2 the health record and any documentation within that record is a legal document that can be used in the court of law; for this reason there is no margin for error.   For this assignment you are to review the case study provided which outlines a true account of unprofessional conduct. Once you have reviewed the case study, you will need write and upload a reflective essay to D2L Dropbox. The essay must include an assignment title page, be in essay format, include an introduction and conclusion, be 2 to 3 pages in length, and single spaced using Calibri (Body) 12 point font. Make sure that you are addressing the following in your essay: In the case study, the nurse failed to properly prepare a client for a colonoscopy; instructed the Health Care Attendant to provide breakfast to a client that was to remain NPO for surgery later that day and did not document this on the pre-operative checklist.                o Who does this impact and how?                o What tasks would the Hospital Unit Clerk need to complete as a result? Explain the effects lack of proper documentation can have on the client, nursing staff, and you as the Hospital Unit Clerk. Based on the College & Association of Registered Nurses of Alberta definition of “fitness to practice”, what are some ways an HUC can show they are fit to practice? As an unregulated profession do you think the same standards should be expected of HUC’s? What have you learned from this assignment? *Note: All sources used must be cited using APA format. CARNA Member Registration number:    A Hearing Tribunal made a finding of unprofessional conduct against member #86,659 who failed to document a post-operative assessment and care of a patient in a timely manner, or advise the next shift that the patient had not been given a dose of Septra; and who, on the next day regarding the same patient, failed to document vital signs q4h as ordered; failed to document pain assessments; failed to complete or document thorough assessments on this patient, who had been febrile, earlier in the day. The member failed to give Colyte to her patient in preparation for a colonoscopy.   The member incorrectly applied a VAC dressing to a patient. The member mistakenly told an HCA to give a patient breakfast, when the patient was supposed to be NPO, in anticipation of surgery later that day, and then failed to document in the pre-operative checklist that the patient had eaten breakfast. On another shift with another patient, the member failed to document on the pre-operative checklist that the patient had eaten breakfast; and failed to appropriately document an assessment of the patient’s new CVC insertion site.   The next day, the member failed to apply the correct dressing to the new CVC line, failed to document that the jugular CVC line had been removed; and flushed the CVC line at the incorrect time and with the wrong solution. The member failed to provide adequate care to a patient when she failed to appropriately document the patient’s blood glucose level; failed to check the patient’s medication orders; and failed to document any patient assessments.   The member failed to provide adequate care to another patient when she failed to do or document an adequate patient admission and history; and failed to document: vital signs, assessments of IV and urostomy sites; pain assessments; administration of Fragmin; administration of a saline flush; and the failure to insert the ordered NG tube.   The member was issued a reprimand and required to pass the following courses: assessment; clinical nursing skills refresher; documentation; basic medication administration; central venous catheter care. She is not allowed to practise pending medical clearance, and then she is restricted to working under supervised practice, and must provide two satisfactory performance evaluations. She is also required to provide ongoing proof of medical fitness to practise. Conditions shall appear on the member’s practice permit. Failure to comply with the Order may result in suspension of CARNA practice permit.   *CARNA Alberta RN Magazine: Summer 2016 Volume 72 No 2 (, Publications ordered by Hearing Tribunals (pages 13-14). Answer :- Fundamental or medical order INTRODUCTION In the clinical set up, documentation and sticking within the Standard Operating Procedure are one of the key requirements where any healthcare profession is regulated or not. This two acts will go a long way in ensuring that the patient is subjected to the much needed care. In any case one has flaws, then it is bound to create casualties whereby the patient might be subjected to the wrong medication and legal suits might follow the nurse (Esquibel, 2011). In this assignment, a case study on a patient who was subjected to breakfast prior to colonoscopy and improper documentation by the HUC will be analyzed. DISCUSSION From the case study, it was very clear that the nurse did not effectively prepare the client for a colonoscopy exercise. The nurse did achieve this by providing breakfast to the patient which is totally against the guidelines of the colonoscopy exercise. This act is likely to affect both the nurse and the patient in that to the nurse, it is likely to attract a legal suit in case the family members or rather the patient learns this. On the part of the client, he is likely to be affected in the sense that he might not be subjected to the needed medical care due to the faulty results that might be obtained as a result of a full bowl during the exercise In the hospital set up, documentation plays a very critical role towards defining the type of care that should be provided to the patient. This therefore means that the whole process should be as flawless as possible. However, according to the above case study where I experienced improper documentation of a patient who was in need of a colonoscopy procedure and the Hospital Unit Clerk failed to provide proper documentation (Seto & Inoue, 2016). The effects of such acts are quite numerous and they affect both the nurse, the client and the Hospital Unit Clerk. Going by this case for example, proper documentation was required indicating that the client had eaten something. Failure to indicate that made the colonoscopy procedure to miss indicating the lesions in the stomach and this therefore affected the client in the sense that he never received the much needed medical attention targeting the lesions. On the part of the nursing staff, lack of proper documentation is likely to lead to a legal suit since incase the patient dies from a complication that did result from a wrong documentation, the family members are likely to file a case which both the Hospital Unit Clerk and the nursing staff would be liable to answer. According to the College and Association of Registered Nurses of Alberta, fitness to practice can be precisely defined as the possession of necessary skills to effectively and efficiently carry out your roles as a healthcare profession. This therefore means that for one to be fit to practice, they have to avoid all flaws as possible in the clinical set up. This was however not the case as per the case study since the HUC failed to document the necessary information (Selvi, 2017). For a HUC to demonstrate that they are ready to practice, they have to provide a detailed and clear documentation of all the occurrences prior, during and after the medical intervention on a patient so that proper care or services are provided to the patient. Whether as an unregulated or regulated healthcare profession, all the required standards ought to be expected at all times. This is because the life of the patient is always at the stake of the healthcare professions and the issue of unregulated should not be used as an excuse to provide poor quality services to the patient. What I have learnt from this case is that proper documentation is very key in the clinical set up as it acts as the guideline that the doctor, nurses and all the hospital staff work along in ensuring the patient gets the best services. In any case improper documentation takes place, then there would be flaws in the whole process. Like in this case where there was no documentation about the patient who ate breakfast, chances are very high that the colonoscopy results will be faulty as they can miss out ot indicate the lesions that might be in the stomach. It should therefore act as a lesson to me and all healthcare professions that documentation is a very essential practice that should always be adhered to whether one is regulated or unregulated. CONCLUSION It is very clear that in this case study that the nurse failed to follow the necessary guidelines or the standard operating procedure when handling the patient by providing breakfast prior to colonoscopy. The HUC on the other hand failed to provide proper documentation of the scenario. This kind of flaws are known to negatively impact both the nurse, the patient and the HUC. It is therefore the duty of any healthcare profession to adhere to the necessary guidelines so that the client is subjected to the best care possible.

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