Importance of Proper Documentation in Healthcare

This article discusses the importance of proper documentation in healthcare through a case study on a patient who was subjected to breakfast prior to colonoscopy and improper documentation by the HUC. It highlights the negative impacts of improper documentation on both the healthcare professional and the patient. The article emphasizes the need for adherence to necessary guidelines and standards to ensure the best care possible for the patient.

RUNNING HEAD: FUNDAMENTAL OF MEDICAL ORDER 1
Fundamental of medical order
Name:
Institution:
Tutor:
Date:

FUNDAMENTAL OF MEDICAL ORDER 2
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

FUNDAMENTAL OF MEDICAL ORDER 3
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.

FUNDAMENTAL OF MEDICAL ORDER 4
References
Esquibel, L. (2011). Proper documentation is good for patients and staff. Nursing Standard,
25(36), 33-33. doi:10.7748/ns.25.36.33.s47
Selvi, S. T. (2017). Documentation in Nursing Practice. International Journal of Nursing
Education, 9(4), 121. doi:10.5958/0974-9357.2017.00108.8
Seto, R., & Inoue, T. (2016). Nursing Documentation Improvement at Post-Acute Care
Settings. Proceedings of the International Conference on Information and
Communication Technologies for Ageing Well and e-Health.
doi:10.5220/0005892101630168