Scope Of Practice And Importance Of Proper Medical Documentation In Healthcare

Discussion

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.