Transcribing Medical Orders

Running head: TRANSCRIBING MEDICAL ORDERS
TRANSCRIBING MEDICAL ORDERS
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TRANSCRIBING MEDICAL ORDERS
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Introduction:
In the healthcare organization, each and every healthcare staff have some professional
boundaries which plays an important role in providing quality care to the patient. One of the
professional boundaries for the registered nurse is to conduct the documentation properly
(Ashton, 2016). This essay mainly focusses on the 5 documentation error observed in the case
study and its effect on the other healthcare department and patient’s care.
Discussion:
Documentation is referred as the critical vehicle used to convey essential medical
information about the diagnosis, treatment and the outcome of the patient (Lavin, Harper & Barr,
2015). From the case study, it can be identified that the nurse have done several mistakes related
to documentation. 1st documentation mistake observed in the case study is that the nurse had
failed in documenting the vital signs every four hour as ordered. 2nd documentation mistake is
conducted by the nurse while a patient is going for operation. The nurse failed to conduct the
pre-operative checklist which includes the information regarding the diet such as the patient had
breakfast or not. 3rd documentation error had been observed during the dressing of the CVC line,
the nurse failed to document that the jugular CVC line has been removed or not and flushed it
with the wrong solution at the wrong time. 4th documentation error identified in the case study is
the inappropriate documentation of the blood glucose level (BGL) of the patient, which can be
considered as the barrier in providing quality care of the patient. 5th documentation mistake
observed in the case study is failed documentation of the patient’s history and admission.
Documentation errors is referred to as the documentation of the false information or the
missing information. Documentation errors of the nurses can lead to medical errors due to the