In this document we will discuss about Fundamentals of Medical Orders and below are the summary points of this document:-
The importance of documentation in healthcare and how failure to document important patient data can result in unprofessional conduct.
The article presents five examples of unprofessional conduct related to documentation in a case study, including failure to document vital signs, assessments, admission history, CVC insertion site assessment, and whether the patient had eaten breakfast before surgery.
The article explains how different healthcare professionals are affected by each example of unprofessional conduct.
Additionally, the article discusses the role of a hospital unit clerk in preventing such unprofessional conduct and ensuring accurate documentation.
The article concludes that healthcare professionals should adhere to documentation principles to maintain successful patient care and avoid legal liability.