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HUCL1301 : Fundamentals Of Medical Order

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HUCL1301 : Fundamentals Of Medical Order Question 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). 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. Address The Following In Your Essay: Using the information in the case study provide 5 examples of unprofessional conduct in relation to documentation committed by the nurse. List 5 professionals/departments who could be impacted by these acts of unprofessional conduct. Answer Examples Of Unprofessional Conduct In Relation To Documentation Committed By The Nurse The member is guilty of committing several unprofessional conducts regarding documentation. She did not record a postoperative assessment and care of a patient on time. Furthermore, on the other two occasions, she did not twice record pre-operative checklist that the patient had taken breakfast and yet he/she was due for surgery. Saranto and Kinnunen  (2009) observe that it is not only required in nursing practice that a nurse document every step advanced in the treatment of a patient but the principles of nursing practice demand that the documentation is correct, clear, and available to ensure safe, quality care, evidence-based nursing practice. The member did not also record vital signs as directed or even document enough patient admission and history. According to Castledine (2006), the accurate measurement and documentation of the critical signs of a patient are significant as it shows the physiological state of the patient. It is a nursing practice that vital signs of a patient are documented upon arrival to the ward, emergency department, or at the registry before, during and after the procedure.  Failed to document pain assessments. The assessment and documentation of pain are significant in providing quality pain management. According to a review conducted by Oldenmenger et al. (2009) on hindrance to cancer pain management, the authors found out that the absence of pain assessment and sometimes documentation was the leading hindrance to attaining good pain control and management. Did not take notes about thorough patient assessments. The nurse did not only fail to document two occasions of patient assessments but also never recorded any. Comprehensive documentation of patient assessment is significant insignificant in determining the appropriate medication and hence the provision of quality care. Voepel-Lewis, Zanotti, Dammeyer, and Merkel (2010) found out that lack of documentation of patient assessment led to wrong documentation after some period due to the nurse forgetting or when handing over shifts. The nurse also did not correctly document various treatments administer to patients such as an assessment of the new CVC insertion site of the patient. This none documentation of administered procedures makes it difficult to track the healing process of the patient Professionals/Departments Who Could Be Impacted By These Acts Of Unprofessional Conduct The unprofessional conducts of the nurse will affect most of the major hospital departments or professionals. Hospital Administration The misconduct is likely to generally affect the hospital administration because such a heightened level of negligence will bring a bad reputation to the hospital as a whole. Lange, Lee, and Dai (2011) note that the goodwill of any organization is behind the general administration. Furthermore, such negligence is likely to lead to deaths or low-quality health care, which will clearly show that the management has failed to run the hospital. Accident And Emergency Department The member doesn’t make any documentation of almost all cases that she handles, and if she makes any, it is not done promptly. This is critical because efficiency and effectiveness are required in the emergency department. Additionally, she does not only fail to document any patient assessment and treatment but also does it in an untimely manner. Such unprofessional conduct will affect the productivity of the emergency department as a whole because it is generally believed that medical practitioners work as a team but in the actual sense each individually assigned responsibilities (Nussbaum, 2009). General Surgery There are two instances where the member fails to record relevant information associated with an operation. For example, she did not record in the pre-operative checklist that the patient had taken breakfast. This will affect the entire surgery department because it is a medical standard practice patient anticipating surgery procedure should not consume food eight hours to the surgery. The failure or complications of the surgical procedure as a result of the professional misconduct will negatively implicate the entire team. Nursing Department The many professional misconducts of the member will negatively affect the nursing department since she is also a nurse. The consequences of professional negligence will make people question the qualification of the entire team of nurses in the health facility. As a result, clients will try to avoid the services of the hospital. Nurse reputation is dependent on the quality of healthcare services. College And Association Of Registered Nurses Of Alberta (CARNA) The nurse is already a registered member number 86,659, meaning that he/she is a qualified practicing nurse. However, the kind of unprofessional conduct exhibited by her raises serious concerns regarding the credibility and professionalism of CARNA. The work of professional bodies in the nursing profession such as CARNA is to ensure that quality healthcare is provided by qualified expert nurses (CARNA, 2011). Tasks The Hospital Unit Clerk Would Need To Complete As A Result Of The Unprofessional Conduct The hospital unit clerk is responsible for documenting patient care services by obtaining such information from the records of the nurses and doctors and then posting them to the patient department records (Kelley, Brandon, & Docherty, 2011). As a result of the unprofessional conduct of the nurse, the hospital unit clerk will have to document the post-operative assessment by obtaining information from the negligent nurse or the officer in charge of the patient. The clerk is also responsible for updating on-call board each shift as required. The clerk is to provide updates on the incoming shift and correct the failure of the nurse to advise the incoming shift on the septra dose medications not given to the patient. The clerk is also responsible for completely logging each patient’s visit. The clerk will have to go through each admissions of all the patients and document the undocumented information such as vital signs, pain assessments etc. The clerk also pulls charts for medical records routinely. For example the clerk will have to update all undocumented medical records (such as blood glucose level, medication orders of the patients) each time he/she pulls them out. The clerk documents the patient’s profile and medication history. He/she will have to document the undocumented medication history such as saline flush and fragmin administration. Conclusion The first step toward offering healthcare services is patient assessment and documentation. Documentation in nursing is critical for evidence-based nursing practice and failure to clearly make appropriate documentation and on time is deemed unprofessional misconduct that can lead to the suspension of practice permit. The several instances of professional misconduct by the nurse raises concerns with the credibility and professionalism of the College and Association of Registered Nurses of Alberta. References Castledine, G. (2006). The importance of measuring and recording vital signs correctly. British journal of nursing, 15(5), 285-285. College and Association of Registered Nurses of Alberta. (2011). Scope of Practice for Registered Nurses. Kelley, T. F., Brandon, D. H., & Docherty, S. L. (2011). Electronic nursing documentation as a strategy to improve quality of patient care. Journal of nursing scholarship, 43(2), 154-162. Lange, D., Lee, P. M., & Dai, Y. (2011). Organizational reputation: A review. Journal of management, 37(1), 153-184. Nussbaum, A. S. K. (2009). Ethical corporate social responsibility (CSR) and the pharmaceutical industry: A happy couple?. Journal of Medical Marketing, 9(1), 67-76. Oldenmenger, W. H., Smitt, P. A. S., van Dooren, S., Stoter, G., & van der Rijt, C. C. (2009). A systematic review on barriers hindering adequate cancer pain management and interventions to reduce them: a critical appraisal. European journal of cancer, 45(8), 1370-1380. Saranto, K., &Kinnunen, U. M. (2009). Evaluating nursing documentation–research designs and methods: systematic review. Journal of advanced nursing, 65(3), 464-476. Voepel-Lewis, T., Zanotti, J., Dammeyer, J. A., & Merkel, S. (2010). Reliability and validity of the face, legs, activity, cry, consolabilitybehavioral tool in assessing acute pain in critically ill patients. American journal of critical care, 19(1), 55-61.

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