Importance of Proper Documentation in Healthcare: Lessons for Health Unit Coordinators

Running head: HEALTH UNIT CLERKS
HEALTH UNIT COORDINATORS
Name of the student:
Name of the university:
Author note:

1
HEALTH UNIT CLERKS
The nursing professional who was given the duty to take care of the patient had failed
miserably in meeting the quality and safety standards required to provide quality care to the
patients. The various types of errors that she had made could have severe consequences on the
health of the patient. One of the biggest errors made by her was the improper documentation
about the actions she had taken as well as the medications that should have been provided to
the patient. She had not documented that the medicine was yet to administered by the nurse
of the next shift (Hognes et al., 2016). She had not documented any vital signs neither had
properly documented the pain assessments of the patient in her records. Moreover, she had
also not provided colyte to the patient for preparing her for colonoscopy and had provided a
VAC dressing to the patient incorrectly. Many severe mistakes had taken place due to a number
of facts (Geurden et al., 2014). The first issues was found to be her inability to maintain
documentation and the second issue was that she was not well skilled or knowledgeable or that
she was careless with her responsibilities. Not only the patient would suffer longer stays at
hospital or life threatening situations and higher amount of suffering the nurses would be held
under legal actions that may affect her career and her license may get cancelled (Okaisu et al.,
2014).
I have realized that nursing records can act as a tool for effectively documenting as well
as planning and evaluating patient care. I have understood that medical as well as nursing
records can stand out as one of the most important means of communication among the team
members of healthcare professionals who are providing care to the patients. Information in the
chart not only helps to maintain the records of the patient even after she has been discharge
for future referrals but also is important in other ways. Documentations mainly help the other
medical workers understand how the patient is being treated (Goldberg et al., 2014).
Researchers are also of the opinion that medical charts also provide information in the event of
the legal actions or different concerns. Moreover, besides effectively communicating different
information about the patient’s health, it also helps to evaluate and monitor the progress of the
client and thereby help in understanding how the patient is responding to the treatment
(Okoniewsika et al., 2015). If the pain assessments were properly conducted and documented
from time to time, the professionals can understood how the patient is responding the
treatment of pain management and whether her pain has ceased over time or not. Moreover, I
have realized that she had also not documented a postoperative assessment successfully and
had not stated the other nurse that medications of Septra were not provided. This could have
easily led to a case of medical error that could have causes severe threatening situation to the
life of the patient. Proper skills and knowledge along with responsible behavior towards nursing
professional were both found to be missing in the professional and hence she was held under
legal obligation (Daniels et al., 2016).
My duty as a health unit coordinator is to perform the administrative duties thereby
acting as liaisons between the patients, doctors, nurses in the healthcare facilities. We are given
special training for development of the medical as well as legal knowledge and at the same
time, we have to take care that we provide better customer service and communication skills.
In this case, scenario, I have to take up the duty of documenting the physician’s order and
thereby prepare the patient treatment charts. I have to update all the information of the chart